Dental Authorization Form

Please fill out the following form before your scheduled appointment with us!

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Dental Authorization Form

Thank you for choosing Santa Rosa Veterinary Hospital. Please fill out the following form as thoroughly as possible so we can get to know your pet before their appointment with us. If you are in need of immediate assistance, please contact us at 707-544-1313.

It is very difficult to thoroughly examine an animal’s mouth in the exam room. We need to check every surface, probe every pocket, and x-ray all the teeth. Until we have thoroughly examined your pet’s teeth in detail under anesthesia, we cannot know how extensive his/her dental procedure will be, if there is a need for extractions, or if other more advanced techniques are needed. Therefore, we cannot provide an absolute estimate of the cost for dental procedures. We will try to contact you if anything other than a routine cleaning procedure is needed.

If we cannot connect on the phone while we are working, how would you like us to proceed:


ALL Animals are dismissed only during office hours: Monday thru Friday from 9am to 6pm Saturday from 9am to 2pm. We are closed Sundays.


I certify that I own the above described animal and I do hereby consent and authorize the Santa Rosa Veterinary Hospital, and its staff to hospitalize my pet, and to administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that the Doctor deems necessary for the health, safety, or well-being of the above animal while it is under their care and supervision.I agree to pay all fees incurred in the treatment of my pet.You are to use all reasonable precautions against injury, escape, or destruction of the animal, but you will not be held liable for any problems which might arise from the care, treatment, or safe keeping of the animal as it is understood that I assume all risks.I understand that if surgery or anesthesia isto be performed, that there will inevitably be some degree of risk, and that it is not possible for you to guarantee a successful outcome of any medical problem.If animal is not picked up within fourteen (14) calendar days after the day the animal was due to be picked up, said animal will be considered abandoned. For a minimum of ten (10) days, efforts shall be made to find a new home for said animal and if home is not found, said animal shall be humanely destroyed. It is understood that you’reso doing does not relieve me from paying all costs of your service and the use of your hospital, including the cost of keeping.I understand that veterinary service during nighttime hours and weekends is provided at the discretion of the veterinarian incharge. Continuous presence of personnel may not be provided during these off hours.I have read the foregoing and agree.