"*" indicates required fields

Thank you for entrusting us with your pet’s care! Please take a moment to complete this form for your pet’s upcoming dental procedure and don’t hesitate to contact us at 615-383-1000 or at [email protected] if you have any questions.

Account Holder's First Name*

Account Holder's Last Name*

Pet's Name*

Primary Contact Name*

First & Last Name

Phone Number for Day of Procedure*

Secondary Contact Name

First & Last Name

Secondary Contact Phone Number

Current medications (including monthly preventatives)*

Include name, strength, dose and frequency of medication, please be prepared to share the date and time the last dose of each medication was given when your pet is admitted.

Additional Requests or Procedures*

Please understand that certain additional procedures will have to be approved by the attending veterinarian.

Please review the following options regarding teeth extractions and choose one option below*

If teeth extractions are indicated, I authorize all necessary extractions

If teeth extractions are indicated, I would like to be called prior to extractions. If iI am unavailable, I understand the decision for extractions will be at the doctor’s discretion.

While your pet is under anesthesia, we can implant a microchip. Microchips have helped reunite thousands of lost pets. With a current annual membership (first year included with implant) the microchip also includes 24-hour emergency support, free poison control, and more. Would you like us to microchip your pet today?*

Yes

Already Microchipped

It is important that patients undergoing anesthesia be fasted before the procedure, while water is ok – all food should be withheld from your pet after 8:00pm the night before the procedure.

By typing my name below, I hereby state that I am the owner or authorized agent for the owner of the animal identified above and authorize the veterinarians at Belmont Animal Hospital to perform such diagnostics, treatments, and/or surgical procedures as deemed necessary for my pet. The nature and risk of the procedure(s) have been explained to me and no guarantee has been made as to the results or cure. I fully understand that there may be risk and the potential for complications including death. I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances and understand that an itemized estimate for the cost of the procedure(s) is available upon request. I have read the above conditions for treatment and acknowledge that I may have a copy of this form, if requested.*

Your Name*

Today's Date*

This field is for validation purposes and should be left unchanged.

What's Next

1
Call Us or Schedule an Appointment Online
2
Meet with a Doctor for an Initial Exam
3
Put a Plan Together for Your Pet

Make an Appointment

Dental Consent Form

What's Next

Call Us or Schedule an Appointment Online

Meet with a Doctor for an Initial Exam

Put a Plan Together for Your Pet

Where family pets find loving care