Dental – Burrard Animal Hospital

Authorization Form - Dental

THANK YOU for choosing our Hospital! Please feel free to contact us if you have any questions regarding any of our services. IMPORTANT: Service dates and arrangements are not confirmed until you have received notification. A staff member will contact you by phone or email.

Authorization - I Am Authorizing The Following Procedures: Blood Work, IV Fluids, General Anesthesia, Dental Prophylaxis, Dental X-Rays, Antibiotic Injection, Nail Trim, Possible Dental Extraction, Possible Analgesic Injection, Possible Medication To Go Home.*
- Accept
- Decline
IF YOU CHOOSE DECLINE PLEASE DO NOT FILL OUT THE FOLLOWING FORM AND CALL OUR HOSPITAL.
Name*
First Last
Email*
Phone*
Pet Name*
Has your pet been here before?*
- Yes
- No
Please fill out any Comments or Special Instructions below: (Request for additional veterinary services, etc.)
Drop off Date*
Date Format: MM slash DD slash YYYY
Drop off Time - Must Be Between 7a.m. - 9a.m.*

: HH

MM
I can be contacted at anytime during the day of the procedure at the following number:*
First Last
Phone*

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Authorization Form - Dental

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