Professional Dental Cleaning And Treatment Release Form

Please complete the following form before your visit!

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Professional Dental Cleaning And Treatment Release Form

Consent and Authorization Statements

Name *

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Last

Email *

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I authorize the attending veterinarian to proceed withany treatment needed in relation to my pet’s oral health. This may includeoral surgery (extractions)as deemed necessary. (There may be an additional charge associated with unforeseentreatment or extractions)

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I would like a call if treatment needed for my pet’soral health is to exceed the estimate provided to me by the staff of Fitchburg Veterinary Hospital.

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I decline to have the doctor(s) perform necessary treatmentif I am not able to be reached. I understand this willend the procedure after cleaning iscomplete. I understand this will mean an additional surgical procedure to performtreatmentwillbe necessary at a later date.

By signing below you are authorizing Fitchburg Veterinary Hospital to proceed and you accept full financial responsibility for all diagnostic tests and treatment included in the estimated fee range and for any additional emergency services should they be necessary.

Full payment is expected at the time of discharge.

I have read and understand this authorization and consent

I have read and understand this authorization and consent

Signature *

Clear Signature

Date *

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Professional Dental Cleaning And Treatment Release Form

Professional Dental Cleaning And Treatment Release Form

Consent and Authorization Statements

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