Dental and Anesthesia Release: Feline Dental in Portland, TX

Owner*

Patient*

Procedure*

Is your pet on any medications?*

Date Checked In*

Pick-up Date*

Phone where you can be reached today*

I hereby authorize Dr. Fontanez of Portland Veterinary Hospital to perform the above stated procedures, as well as any other treatment that they deem necessary for the health and well-being of my pet while under their care. I understand that I will be informed of any changes in the estimated fees due to unforeseen circumstances. The nature of the procedure has been explained to me and No guarantee has been made as to the results or cur. I understand that there are always risks involved with any surgery or anesthetic protocol, but that precautions will be taken to minimize risks involved with any surgery or anesthetic protocol, but that precautions will be taken to minimize risks as much as possible. I understand that my pet will be released during office hours only, and that Full PAYMENT IS REQUIRED UPON RELEASE OF MY PET.

I understand that should my pet injure itself in an attempt to escape, refuse food, suddenly become ill and die, or succumb to the effects of natural disasters (Hurricanes, Lightening, Tornadoes), I cannot hold Portland Veterinary Hospital liable in the absence of gross negligence as provided by state law.

Feline Dental

Owners will be charged $7 per tooth extraction if they are needed

Please select all that apply*

All pets will receive a Capstar if not on oral flea control....................$7.20

Dental, Fluids and Pre anesthetic blood work includes CBC (Complete Blood Count), Chemistry Panel (Liver function, kidney function, and Electrolytes), PT/PTT (to check clotting factors)....................$359.86

Dental and Fluids....................$227.66

Dental....................$192.66

Pain Injection (If Needed) with Laser Therapy....................$25.50

Medication to go home. Approximate cost....................$30.00

Ear Cleaning....................$14.25

Nail trim....................$7.25

Prices noted are estimated costs subjected to change

Total ($)*

Signature*

Date*