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Dental Procedure Form

Disclaimer

PAYMENT IS REQUIRED IN FULL AT THE TIME SERVICES ARE RENDERED. ACCEPTABLE FORMS OF PAYMENT ARE CASH, AMEX, VISA, MASTERCARD, DISCOVER, CARECREDIT, AND SCRATCHPAY (CHECKS WILL NOT BE ACCEPTED).

Full Name

Pet's Name

Address

Primary Contact Name (change if necessary)

Primary Contact Phone

Secondary Contact Name

Secondary Contact Phone

When was the last time your pet ate?

Is your pet on any medication?

Is your pet on any medication?
A
B
OraVet Barrier Sealant binds electrostatically to tooth enamel, creating an invisible barrier that helps prevent plaque-forming bacteria from attaching for two weeks. OraVet Barrier Sealant has been clinically shown to significantly reduce the formation of plaque when followed by use of OraVet Plaque Protection Gel.
Oravet Sealant
A
B
Home care is an important part of your pet's dental health regimen. Weekly applications of OraVet Plaque Prevention Gel, beginning two weeks after your pet's dental procedure, are strongly advised. A take-home supply is a convenient and effective means of helping to reduce further dental problems. You may purchase some to take home during your visit (subject to availability).

I would like to purchase OraVet Plaque Prevention Gel to take home.

I would like to purchase OraVet Plaque Prevention Gel to take home.
A
B
Purina Pro Plan Veterinary Diet chews (dogs only), as well as brushing your pet's teeth with a Pet Toothbrush Kit, are also recommended as home care, as an aid in preventing the buildup of tartar and plaque.

I would like Purina Dental Chews

I would like Purina Dental Chews
A
B

I would like a Pet Toothbrush Kit

I would like a Pet Toothbrush Kit
A
B

Dental Extractions

I am giving permission to have the extraction of any teeth as deemed necessary by the attending veterinarian.

Initials

Authorization

I understand that my pet must meet any vaccination or diagnostic lab work requirements deemed necessary by the veterinarians of West Hills Animal Hospital. Any necessary vaccines or diagnostic tests will be included on my final invoice and are my responsibility.
I hereby authorize the performance of the above procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure.

Deposit & Payment Policy:

To provide the highest standard of care for your pet, we require a deposit equal to the low end of your provided estimate at the time of admission.
Remaining Balance: If the final cost exceeds the deposit, the remaining balance is due in full at the time of discharge.
Credits: If the final cost is less than the deposit, any resulting credit will be issued back to you during the discharge process.

Signature of Owner or Authorized Agent

Signature

Date