Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Client's Phone Number*Pet's Name* The doctors at Hidden Valley Animal Clinic will do everything possible to preserve and maintain the health of your pet’s teeth. During the course of the examination and cleaning, loose or decayed teeth may be found. Unhealthy and decaying teeth can lead to further health complications for your pet including, but not limited to heart disease. Teeth that need to be extracted are usually either 1) loose or 2) infected. The purpose of dental care for pets is to help them retain as many teeth as possible. However, if your pet has loose or infected teeth they should be extracted for health reasons. Loose Teeth: Teeth that are loose have pockets between the tooth and the gum that holds food particles. Bacteria will grow in the decomposing food. Everytime the animal chews, bacteria is showered into the bloodstream. This creates increased risk of heart and lung disease and puts a continual strain on the immune system. Infected Teeth: These teeth have abscesses at the root of the tooth. As this abscess enlarges it erodes the surrounding bone of the jaw causing the adjacent jawbone and adjacent teeth to also become weakened and infected. If, in the doctor’s professional judgment, these teeth should be removed do you give your consent? Select one of the following options:* Yes, I give my consent for the doctors to use their professional judgment and extract any teeth necessary to maintain my pet’s health. Yes, I give my consent for extractions AFTER I have been called and informed of the situation. If I am NOT available, then I DO give my consent for the doctors to extract any teeth necessary. Yes, I give my consent for extractions AFTER I have been called and informed of the situation. If I am NOT available, then I DO NOT consent for the doctors to extract any teeth. I am aware that the doctors believe teeth may need to be removed and that my pet may have to undergo additional anesthesia in the future to have these teeth removed. If this box is checked, then no teeth will be removed without verbal authorization from the owner. Please acknowledge* I am aware that some teeth may be so loose or diseased that they may just fall out when scaled to remove the tartar.I, _____, have read and agree with the above statement(s).* InitialSignature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
