Medical Authorization and Release Posted on October 8, 2020 by Cheshire Required Fields Are Marked [*] "*" indicates required fields Please Complete 2 Days Prior To Your Pet's Surgical ProcedureName* First Last Phone number where you can be reached today:*Additional phone number:*Email* Pet's Name* Does your pet have any food restrictions?* YES NO If YES was selected, please explain:*Is your pet under 15 lbs?* YES NO If your pet is under 15 lbs, please make a selection:* I prefer liquid medication I prefer tablet medication Please list all current medications your pet is taking?I hereby authorize the Animal Dental Clinic, and their staff members to administer treatment and perform diagnostic procedures and surgeries that are deemed necessary based on the findings of our evaluation. I consent to the administration of anesthetics and sedatives that are appropriate to perform such procedures.* I authorize I certify that I have read and understand the above authorization. I also certify that no guarantee or assurance has been made as to the results that may be obtained, and that complications may arise from procedures.* I do Hospital Policy: Animal Dental Clinic abides by a veterinary referral Code of Ethics. If your pet has been referred by your veterinarian for treatment by the Animal Dental Clinic and requires medical attention unrelated to an oral condition, please contact your primary care veterinarian for further assistance.* I understand and I agree Dental procedures are not always predictable, but when possible we like to work within your afternoon schedule to arrange a pick up time for your pet. Surgical discharges times may vary.* I understand and I agree Your pet will be shaved for IV Catheter and Blood Pressure monitoring.* I understand and I agree Payment: Payment is due at the time of service. We accept Visa, Mastercard, Discover, Care Credit and Debit cards, in addition to checks and cash. I certify that I assume financial responsibility for all charges incurred to this patient and authorize direct payment to the Animal Dental Clinic. I understand and I agree Credit: The Animal Dental Clinic cannot extend credit.* I understand and I agree I agree to the release of photos, radiograph or testimonials of my pet for Animal Dental Clinic’s use for continuing education, ADC’s website or Facebook page.* I ACCEPT I DECLINE Signature (Owner/Responsible Party)* Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY You must click on the Submit button below after you verify the Captcha code.CAPTCHANameThis field is for validation purposes and should be left unchanged.