Dentistry Release Form Owner* First Last Patient's Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Species* Canine Feline Who can be reached on the day of the surgery?*NameNumberCell / Home / Work It is not possible to thoroughly evaluate the teeth and gums until your pet is anesthetized. Each tooth must be evaluated before a decision is made as to the best course of treatment. The teeth are cleaned with an ultrasonic scaler to remove tartar. After that a dental probe is used to check around each tooth. If problems are found then dental x-rays may be needed to determine the extent of the problem. Any teeth that are fractured or have missing enamel may need to be extracted (here), or need root canal therapy done elsewhere at a later time. In addition, any tooth that is loose or where the bone around the tooth roots has been lost from periodontal disease should be extracted. Cats develop cavity-like lesions at or below the gum line and the only treatment for these painful teeth is extraction. After the oral examination and possible x-rays the doctor or technician can call you (as indicated below) about any problems found and discuss the options for whatever further oral surgery is indicated. The oral surgery may be able to be done at this time or scheduled for another date. It is more economical to complete all needed dental procedures during the initial anesthetic session rather than schedule a separate procedure at another time.The following choices are available:* The doctor has permission to do whatever treatments or extractions are deemed necessary I would like to be contacted prior to any extractions. After the initial cleaning is done and problems have been addressed, the teeth are polished, the gums are flushed with antiseptic and a fluoride treatment is applied. Antibiotics and pain medications are prescribed as needed. A geriatric blood profile is REQUIRED for geriatric patients or patients with health problems before undergoing anesthesia. Pre anesthetic blood screening is recommended for ALL patients, but is optional. If your pet is under 8 years of age, please accept or decline the below recommended procedure:Pre-anesthetic bloodwork for healthy patients under 8 years of age Yes No Date MM slash DD slash YYYY I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED.* Type NameANY patient that is hospitalized is required to have a current rabies and distemper vaccine. If there is no proof of vaccine upon admission, your pet will be vaccinated while hospitalized and charged accordingly!