Dentistry Consent

Thank you for choosing Highline Veterinary Hospital for your pet’s needs!

First things first…

Please complete the form below, and a member of our team will get back to you soon. If you have any questions, please feel free to contact us. Please Note: Any fields with * are required.

Owner's Name *

First

Last

Pet's Name *

Phone *

Alternate Phone

Email *

Has your pet eaten this morning? *

After your pet’s procedure, we would like to offer your pet a small meal. What can we feed your pet? *

Has your pet had morning medications? *

If your pet has had morning medications, please specify below (type): *

Does your pet need a prescription refill today? *

Please specify. *

Have you received an estimate for services? *

Yes
No (If selected, a staff member must be able to reach you with an estimated cost prior to treatment.)

Our goal is to preserve all teeth and extract only those that are hopelessly diseased. During the oral examination and cleaning, we may discover additional problems. Please refer to the questions below. In the event we are unable to contact you, we will perform only those procedures you have marked below.

Permission is granted to...

Perform general anesthesia to perform the dental exam, x-rays and cleaning: *

Extract any diseased teeth: *

I authorize additional procedures the doctor feels is necessary and will pay the additional charges. *

I authorize additional procedures the doctor feels are necessary and will pay the additional charges.

I authorize additional procedures the doctor feels is necessary and will pay the additional charges. *

I authorize necessary procedures / expenses up to *

I authorize necessary procedures / expenses up to:

Amount authorized *

I authorize additional procedures the doctor feels is necessary and will pay the additional charges. (copy) *

If medication is sent home, which of the following would you prefer administering? *

Liquid
Pills

What type of dental care are you willing and/or able to perform at home? *

Dental Diet
Chewing Products
Daily Teeth Brushing

Any additional procedures being done today?

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree.

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the staff's abilities at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree.

Signature *

Clear Signature

Date *

Comment

Your other family doctor.

The Highline Veterinary Hospital team aims to foster the human-animal bond by partnering with pet parents to help pets live the longest, healthiest lives. We strive to provide excellent preventative care, medical care, and surgical care with our Fear-Free Certified veterinarian staff.

Contact us today!

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Call Us

206-243-2900

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Email Us

[email protected]

Location

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Address

13060 1st Ave S
Burien, WA 98168

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Hours

Mon-Fri: 8:00am - 12:30pm, 1:30pm - 5:00 pm
Sat + Sun: Closed

APPOINTMENT

Have a question?

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Name *