Dentistry Authorization Form Carlson

We thank you for helping us give you the best service possible by completing this
form within 24 hours of receiving.

Please carefully read the following and sign the authorization:

Full mouth dental x-rays are considered the standard of care for evaluating oral health in dogs and cats. X-rays can identify disease below the gum line, which otherwise could go unnoticed and cause severe problems down the line. Please select your preferred option below: *

Please take dental x-rays of all teeth ($225.36 - $338.54 additional cost to printed estimate) Please take dental x-rays of all diseased/questionable teeth ($51.55 per x-ray) Please call me before taking any dental x-rays*

*I understand that if I am unreachable at that time, no further dental services will be performed and my pet will be recovered from anesthesia. This may result in broken or diseased teeth remaining in my pet and additional costs for the future.

In addition to cleaning your pet's teeth, a veterinarian will do a full examination of the mouth under anesthesia. Many abnormalities cannot be detected until an animal is under anesthesia and the calculus has been removed from the teeth. This makes it difficult to predict how many tooth extractions may be needed prior to the procedure. Unhealthy teeth discovered after cleaning may be broken and/or infected and lead to pain. Extraction of these teeth is almost invariably recommended to relieve pain and improve oral health. For any extraction, it is recommended that x-rays be taken before and after extraction to assess the overall health of the tooth and assure complete extraction. Please select your preferred option below: *

Please extract any diseased teeth that cannot be saved with treatment today. (Range is $12.25 – 150.00 per tooth) Please call before any extractions that will make the total cost exceed the high range of the estimate only (otherwise proceed with extractions)* Please call before any extractions*

*I understand that if I am unreachable at that time, no further dental services will be performed and my pet will be recovered from anesthesia. This may result in broken or diseased teeth remaining in my pet and additional costs for the future.

Please select your preferred option concerning taking x-rays after tooth extraction: *

Please take x-rays of teeth after any needed extractions. Please do not take any x-rays after extracting diseased teeth. (This is not advised)

Your pet will receive a complimentary nail trim with this procedure. If there are any additional services you would like to request today, please list them below: *

If not applicable, please write none in the box

I have received an estimate for the prescheduled services. My pet has not had any food since last night. I am the owner/agent for the described animal, and I authorize and request the services listed on this form. I understand and accept that when anesthesia is involved, there are always inherent risks, including death. I have indicated any additional services I would like performed and understand that the services I have requested may be in addition to those provided on the estimate. I understand that pain and/or anti-vomiting medication will be provided if deemed reasonable.

Phone number to reach you during procedure *

Please enter a valid phone number.

Signature *

Clear

Owner First and Last Name *

First Name Last Name

Pet's Name *

Date *

Date

CANCELATION POLICY

While we do understand emergencies and other scheduling conflicts can happen and are sometimes unavoidable, we request a 24-hour notice to change or cancel an appointment. After two missed or canceled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.

Thank you for completing this questionnaire. If you have any questions please call us 708.383.3606

Dentistry Authorization Form

Dental X-Rays

Extractions