Owner's Name______________________________________ Pet's Name__________________________

As part of your pet's dental prophylaxis your pet's teeth will be individually examined and their condition, charted in their permanent health record.  The examination may reveal teeth which require additional work.  We will attempt to call you if unforeseen, non-emergency procedures are needed to correct your pet's dental problem.

However, having to call during the procedure subjects your pets to prolonged anesthesia.  And, if permission cannot be obtained, your pet may need to undergo additional anesthesia and expense at a later date to complete the procedure.  Therefore we would like you to choose one of the following options should unforeseen, non-emergency procedures become necessary.

______I authorized Dr. ________________________ to proceed with all procedures.

______I prefer to be phoned prior to any additional procedures if the charges are in excess of those listed
            below.  The total charge of such unforeseen procedures should not exceed:
                                                                                                           ______ $ 300
                                                                                                           ______ $ 400
                                                                                                           ______ $ 500

______If I cannot be reached, I do not authorize unforeseen, non-emergency procedures.

Signature_____________________________________________________

Phone numbers and times where I can be reached at all times during the day:

____________________________________________________________________________________

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