Dental Authorization Consent Form — Pend Oreille Veterinary Services

I, the owner or agent of the pet identified above, certify that I am over 18 years of age and authorize the staff of Pend Oreille Veterinary Service to perform the above procedure(s). In signing this form I am also giving Pend Oreille Veterinary Service permission to treat my pet as deemed necessary on the basis of the veterinarian's findings during the course of the examination and evaluation; understanding that there is no guarantee that treatment will be successful and Pend Oreille Veterinary Service will not be held liable for any loss that may occur. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Furthermore, I understand that I am financially responsible for all costs incurred during this surgery treatment and hospitalization. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, recheck physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have read and fully understand the terms and conditions set forth above.