I hereby authorize the staff at Westonka Animal Hospital to perform the following indicated procedures:

  Twelve Step Professional Oral Health Care Visit- our recommended, comprehensive level of care

For Steps 1 - 12 (except Step 10)

Canine range - from $278.28 to $378.88 before advanced dental treatments (if recommended)

Feline range - from $236.68 to $330.28 before advanced dental treatments (if recommended)

Step 10 (if recommended) - Advanced Dental Treatments

If Step 10 is needed, which is advanced dental treatments, an oral estimate of the additional charges will be given after the diagnostics are completed before any advanced treatments are performed. Advanced treatments are not part of the initial investment.

---

---

Click here for more detailed information about the 12 Step Professional Oral Health Care Visit. Some examples of advanced dental therapy procedures include tooth extractions, root canals, and gingival flap surgeries

^*If your pet has had a normal blood biochemical health screen within the last three months and did not require a health screen today, your final investment will be reduced by $60.40

It is important that we are able to contact you on the day of your pet's 12 Step Professional Oral Health Visit to discuss the findings of our diagnostic tests and any recommended advanced dental therapy while your pet is still anesthetized. We will not perform advanced dental techniques without your permission. The hospital staff looks forward to contacting clients when the procedures are completed. The telephone numbers where I may be reached today are: # or at # A contact Telephone Number is Required Before Admission To The Hospital If we are unable to contact you, we will wake your pet up from anesthesia without doing the advanced dental techniques.

We ask that you set up a discharge appointment for your pet at the time of admission. There is no additional charge for this brief appointment during which time a technician or staff member will review any relevant reports and home care instructions for your pet and they will answer any questions you may have.

   I also acknowledge that there inherently exists a risk of complications during any sedative, anesthetic, or surgical procedure. The complications can range from mild to life threatening.

   For the safety of all patients in the hospital ward, all surgery patients must be current on rabies and distemper vaccinations. Proof of previous vaccinations must be presented to the hospital. Patient vaccine records which cannot be confirmed by the time of surgery, will have them done at the owners expense.

   We do not allow charging nor billing. How did you plan on paying for today’s services? (please check your answers)
Cash             Check
Visa               Mastercard
Discover       Care Credit  click the hyperlink for more information on Care Credit

   I have read and agree to the above statements:

Signed:  X______________________________