Comprehensive Oral Health Assessment and Treatment

We look forward to seeing you soon! Please complete the form below as accurately and completely as possible. If you have any questions, you can contact us at 419-517-5042.

Client Name *

First

Last

Phone *

Email *

Patient Name

Procedure being performed: Comprehensive Oral Health Assessment (COHAT)

Requested Additional Services:

If your pet is not microchipped: Would you like your pet to be microchipped today while under anesthesia for an additional $36.50?

Yes, please microchip my pet.
No, please do NOT microchip my pet.

We will always call after your pet’s dental radiographs and cleaning have been performed to discuss any needed treatments, including tooth extraction. In the event we are unable to reach you, please choose ONE of the following options (please select your chosen option): *

I approve all veterinarian recommended dental/oral treatment, including tooth extraction, to be performed. I understand I will be responsible for costs associated with this treatment.
I decline any oral/dental treatments to be performed. I understand this may require a second anesthesia event to address any problems identified.

I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. *

I have read and agree

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. *

I have read and agree

I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand a veterinary staff member will be caring for my pet overnight; however no veterinarian will be routinely present in the building overnight. *

I have read and agree

I acknowledge that I received an estimate of cost for this procedure and consent to this estimate of cost. *

I have read and agree

Best phone number(s) to reach you at while your pet is in our care: *

Additional phone number

Last time had food:

Last time had water:

Current Medications:

Special feeding instructions:

Any Preventives (such as Interceptor or Simparica) needed today?

Client Signature *

Clear Signature

Today's Date *

Compassionate veterinary care in Sylvania, OH!

We treat each patient as our own. Our team is here to help when you need us most! We look forward to seeing you.

Location

7851 W Sylvania Ave.
Sylvania, OH 43560

Hours

Mon – Fri: 8:00am – 6:00pm
Sat: 8:00am – 1:00pm

Please Note: We are closed from 1pm to 2pm, Monday through Friday.

Contact Info

Phone: 419-517-5042
Email: info@timberstonevet.com
Fax: 419-517-5044