Name *

First Name

Last Name

Phone *

(###)

###

####

I understand that my pet may have diagnostic blood work preformed today to ensure the health and safety of my pet during any anesthetic procedure. *

Yes

No

My pet is here for a dental and I would like for a 6-month protective sealant to be applied. This sealant will extend the benefits of today’s dental cleaning and continue to promote gingival care. I understand that this is an additional fee. *

Yes

No

I authorize WCAH to extract any teeth that will compromise the future health of my pet. *

Yes

No

I would like for my pet to be Microchipped today. A microchip is a universal identification inserted between the shoulder blades. I understand that this is an additional fee and WCAH will register the microchip. *

Yes

No

I acknowledge that the staff at Williamson County Animal Hospital may need to hospitalize, care for, and perform any procedure(s) that they deem necessary for the health, safety, and well being of the above named pet. I understand that preventative measures will be taken to prevent any unforeseen complications *

Yes

No

I understand that pain medication will be administered accordingly if deemed necessary by a veterinarian, and I will be held responsible for the cost. *

Yes

No

I acknowledge that payment in full is due for services rendered at time of pick up *

Yes

No

Date

MM

DD

YYYY