GVH Dental Authorization

Georgetown Veterinary Hospital

Please update the following information for our records.

Owner Information

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*If you'd like your pet microchipped, please enter your email address above and we will pre-register it for you.

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Pet Information

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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Would you like your pet microchipped today?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If your pet is not already microchipped, we can implant one while they are under anesthesia for $42. (Please provide us with an email address.)

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A dental prophy includes:

A complete scaling of the teeth, polishing, flouride treatment, periodontal charting and an oral examination by the doctor. 

A Grade I (minimal tartar and no gingivitis) dental prophy starts at $349.00. More advanced dental disease requires more time to treat and therefore additional costs will arise.

Owner Consent and Release

Consent to perform extractions and necessary procedures

Many pets require anesthesia before a doctor can complete a thorough dental exam. Each tooth must be carefully evaluated so the veterinarian can choose the best treatment. We recommend completing all meeded dental procedures during this visitso you can avoid scheduling another appointment with additional sedation costs.

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IMPORTANT: Please read these carefully and select ONLY ONE of the above options. 

Would you like any expired vaccines or tests updated? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please be aware that each additional treatment will be performed at additional costs that may or may not be included in your previous estimate.

Release for medical treatment

I, the undersigned, do hereby certify that I am the owner, or duly authorized agent for the owner, of the animal described above and that I do hereby give Georgetown Veterinary Hospital, its veterinarians, agents and/or representatives full and complete authority to perform the dental procedure prescribed above. I also grant permission to perform any other procedure that, at her discretion, may be useful to promote health of the above described pet , and I do hereby and by the presents forever release the said doctor, her agents or representatives from any liability arising from said dental/surgical procedure on said animal. I accept full financial responsibility for all tests and treatments that I verbally authorize during my conversation with the doctor. I understand that payment is due in full when my pet is discharged.

I understand that if evidence of fleas is found on my pet during the examination, a dose of CAPSTAR will be administered at my expense. (Approximately $8)

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No need to enter 1 before the area code.

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No need to enter 1 before the area code.

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GVH Dental Authorization

GVH Dental Authorization

Georgetown Veterinary Hospital

Please update the following information for our records.

Owner Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pet Information

Pet Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Species {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Breed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Would you like your pet microchipped today?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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A dental prophy includes:

A complete scaling of the teeth, polishing, flouride treatment, periodontal charting and an oral examination by the doctor. 

A Grade I (minimal tartar and no gingivitis) dental prophy starts at $349.00. More advanced dental disease requires more time to treat and therefore additional costs will arise.

Owner Consent and Release

Consent to perform extractions and necessary procedures

Many pets require anesthesia before a doctor can complete a thorough dental exam. Each tooth must be carefully evaluated so the veterinarian can choose the best treatment. We recommend completing all meeded dental procedures during this visitso you can avoid scheduling another appointment with additional sedation costs.

Please check ONLY ONE of the options below: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Would you like any expired vaccines or tests updated? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Additional treatments to be performed: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Release for medical treatment

I, the undersigned, do hereby certify that I am the owner, or duly authorized agent for the owner, of the animal described above and that I do hereby give Georgetown Veterinary Hospital, its veterinarians, agents and/or representatives full and complete authority to perform the dental procedure prescribed above. I also grant permission to perform any other procedure that, at her discretion, may be useful to promote health of the above described pet , and I do hereby and by the presents forever release the said doctor, her agents or representatives from any liability arising from said dental/surgical procedure on said animal. I accept full financial responsibility for all tests and treatments that I verbally authorize during my conversation with the doctor. I understand that payment is due in full when my pet is discharged.

I understand that if evidence of fleas is found on my pet during the examination, a dose of CAPSTAR will be administered at my expense. (Approximately $8)

Main phone # where you can be reached today: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Secondary phone # where you can be reached today: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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