Dental Authorization Form

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

cat sitting

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.

Personal items with pet:
ALL Animals are dismissed only during office hours: Monday thru Friday from 8am to 5pm.
Although you have not seen a veterinarian at the time of dropping off your pet, SRVH is authorized to perform the listed procedure(s)/service(s) as approved on the signed estimate. In the event we foresee charges going over the higher end of the estimate or other abnormalities found but not quoted on the estimate we will call you for further discussion and approval of services.
CPR/DNR Release: Your pet is being hospitalized. While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started.

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, and 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. SRVH will use all reasonable precautions against injury, escape, or destruction of the animal, but will not be held liable for any unexpected problems which might arise from the proper care, treatment, or safe keeping of the pet. I understand that if surgery or anesthesia is to be performed, that there will inevitably be some degree of risk, and that it is not possible to guarantee a successful outcome of any medical problem. If the pet 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 or turned over to the county animal control. It is understood that such abandonment does not relieve me from paying all costs of your service and the use of your hospital, including the cost of hospitalization.

I have read the foregoing and agree.