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CORE Form

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

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Online Forms

CORE Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 985-847-0591 for a faster response.

Owner's Name *

Patient's Name *

Breed *

Sex *

Age *

I understand this Procedure requires the use of general anesthesia, and by signing below, I authorize Drs. Perret and/or Richardson to use necessary anesthetics on my pet. *

I have read and understand

I have been informed by the staff of Veterinary Medical Center about the risks involved in the use of anesthesia and/or surgical procedures. I authorize Jeffrey V. Perret, DVM and/or Jeanne Richardson, DVM to perform the procedures described to me and understand should any other procedure be needed during the time my pet is under their care, I will be contacted. I understand that I will not hold or any of Veterinary Medical’s staff members responsible for any complications/death of my pet while hospitalized and during the anesthetic/surgical procedure, in the absence of gross negligence. *

I have read and understand

In the event of additional procedures or extractions are recommended or necessary, and we are unable to get in touch with you, would you prefer we: *

Please do what is medically necessary and in my pet’s best interest. I understand I will be responsible for the additional costs accrued.
Please do what is medically necessary up to $__________. I understand I will be responsible for the additional cost (above the CORE procedure).
Please do not do anything additional beyond the agreed upon CORE Procedure. I understand additional appointments may be required for the completion of my pet’s oral care.

Phone Number(s) where we can reach you at any time while your pet is in our care:

Primary Phone *

Secondary Phone *

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. *

I have read and understand

I acknowledge all services must be paid for when my pet is discharged and Veterinary Medical Center does not offer payment plans. *

I have read and understand

I acknowledge CORE Procedures require a $200 deposit to be made prior to the procedure or at time of hospital admittance. *

I have read and understand

I, the undersigned owner or authorized agent thereof, give consent for the CORE Dental Procedure to be performed on my pet, as described above. *

I agree

Date *

Online Forms

Online Forms

CORE Form

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