Dental Release Form START NOW Dental Release Form Please enable JavaScript in your browser to complete this form.Client Name *Email *During the physical examination, it is often not possible to completley evaluate the degree of dental disease. Only when your pet is under anesthesia can a thorough dental exam be done. We will notify you of any extractions that are necessary. Please initial ONE of the following: 1. I authorize the dental cleaning and any extraction(s) needed regardless of the cost. I do not need to be called for authorization. 2. I authorize only dental cleaning and I MUST be called if any extractions are needed. (Note: Only one attempt will be made to each number provided before proceeding with extractions.) 3. I authorize dental cleaning and extractions up to the limit of my estimate. Please call for any additional costs that may arise. If options 2 or 3 selected, please initial ONE of the following: If I cannot be reached at the phone numbers provided, I give permission to Tillema Veterinary Clinic to provide extractions deemed absolutely necessary by the judgement of the Veterinarian. If I cannot be reached at the phone number(s) provided, I DO NOT give my permission to Tillema Veterinary Clinic to preform any additional extractions without my approval. I understand that my pet will have to undergo additional hospitalization and anesthesia to complete needed treatment. Additional fees may apply and is dependent on individual basis. I have read and completely understand the Dental Release Form and give permission to Tillema Veterinary Clinic to render services to my pet with the above initialed items. *I have read and understand.Signature Owner/Agent Clear Signature(18 years or older)Date *Primary Phone *Alternative Phone Submit
