Dental Authorization Form Pet Name* Owner Name* Owner’s Primary Contact Number* Please select...*HomeCellWorkAlternate Contact Name Alternate Contact # Please select...HomeCellWorkMy pet will have no food starting at 10pm the day before the procedure.* Type your initials here to indicate you understand the above instructions.I hereby consent to and authorize the performance of such procedure(s) as are necessary in the exercise of the veterinarian’s professional judgment. I understand qualified hospital support personnel will be employed as deemed necessary by the veterinarian. I realize that any procedure involving general anesthesia carries a risk, although very small, of death.In such case, I authorize the following measure to be taken:* No Resuscitation External Resuscitation It is often difficult to perform a thorough oral examination, evaluating each tooth while the pet is awake. We may not be able to determine whether extractions are indicated or deciduous teeth are still present until the patient is anesthetized. In all cases, we try to make the best possible decision for the health and comfort of your pet. The cost of this procedure varies depending on how many teeth, if any, require extractions. Dental radiographs are performed with every dental cleaning.Tooth extraction authorization:*Extract whichever teeth necessary. No phone call needed.I wish to be called prior to any extractions.In the event I can't be reached while my pet is under anesthesia:Tooth Extractions:*Extract whichever teeth are necessary.Recover my pet from anesthesia without extracting any teeth.IF FLEAS OR TICKS ARE FOUND ON YOUR PET AT THE TIME OF ENTRY, YOUR PET WILL BE TREATED AND THE MEDICATION WILL BE REFLECTED ON YOUR INVOICE UPON CHECK-OUT.Acknowledgement of flea/tick statement* YES - I UNDERSTAND We offer the Home Again Microchip. Micro chipping is as quick and painless as when we administer your pet its regular vaccinations. More than 10 million pets get lost each year. One third of all pets, including "indoor-only" cats and dogs, will become lost during their lifetime. Unfortunately 90% won't return home without effective identification. The City of San Antonio approved an ordinance amendment (effective 4/30/2015) making a registered microchip the primary means of licensing for pets living within the San Antonio city limits. All dogs, cats, ferrets residing in San Antonio city limits must have a registered microchip and the microchip must be properly registered with the microchip company with the current ownership information. Would you like to ensure your pet a safe return home if he/she ever gets lost?For Microchip purposes, please select one of the following:*YES. Please protect my pet today with a microchip and lifetime registration for $74.69My pet has been micro chipped previously, but I have not yet registered and I WOULD LIKE TO REGISTER my pet today for $35.50.My pet is microchipped and is registered with the updated information.I understand that a microchip can help protect my pet and is required by the City of SA, but I DO NOT wish to microchip my pet today.I hereby authorize the veterinarian perform the procedure listed above-for the described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that all charges must be paid at the time services are rendered and that a deposit may be required for surgical treatment or hospitalization.Please type your Digital Signature:* Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
