Pet's Name:*

*	I am the Owner/Authorized Agent of the above named animal, and I authorize a dental cleaning/polishing under anesthesia to be performed.

Prior to any additional treatment being performed, you will be contacted by telephone when possible.

The phone number(s) where you can be reached TODAY is:

Phone Number 01:

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Phone Number 02:

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Should any unforeseeable dental procedures be deemed necessary in the veterinarian’s professional judgment: (please check one)

	I prefer that you proceed with all necessary dental procedures, including extraction of teeth. (I am aware that additional charges will be incurred as a result of these treatments).
	I prefer to be called before any additional procedures, other than emergencies. In the event I cannot be reached by phone in a timely manner, I authorize you to proceed with all necessary dental procedures. (I am aware that additional charges will be incurred as a result of these treatments).
	In the event I cannot be reached by phone in a timely manner, I do not authorize any additional dental procedures to be performed. (I am aware that in this case my pet may need to undergo additional future anesthesia and treatment at a later date).

Additional elective procedures offered (please check services that you would like performed):

	Nail Trim ($8.40)
	Bath (ask for pricing)
	Ear Cleaning ($28.34-49.75)
	Microchip Implantation ($50.60)
	Anal Gland Expression ($22.89)
	Laser Therapy for post-surgical pain and swelling ($15 )

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The nature of the procedures and the potential risks, have been explained to me and I understand the procedures to be performed. I have received and reviewed a treatment plan for the expected procedures. In the even of a life-threatening emergency, I authorize the attending doctor and the team of Petsadena Animal Hospital to perform procedures deemed medically necessary. I agree that no guarantee has been stated or implied. I understand that I am assuming full financial responsibility for all services rendered at the time my pet is released from the hospital.