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Dental Surgery Intake Form

Please complete this form and submit prior to your arrival at the Hospital for your pet's dental surgery. If you have any questions please call us or email [email protected].

"*" indicates required fields

Owner & patient details

MM slash DD slash YYYY

Health condition history

I understand that my pet must be fasted atleast 12 hours*

Owner's consent

I hereby consent to and authorize the performance of the following required procedures. Prices are found on the estimate provided.*
Dental extractions may be recommended depending on the degree of periodontal disease. Please choose one of the options below:*
Dental radiographs are taken at the Doctor's discretion.*
I hereby consent to and authorize the performance of the following additional procedures. Prices are found on the estimate provided.*
e.g. Simparica Trio, 3 doses