Pet Parent's Name *

First

Last

Email *

Please confirm your pet's name: *

Date of Birth *

How long have you had your pet & where did you get them from (rescued pet, breeder, etc)? *

What is prompting your visit to our Dentistry Service? *

How long has this been going on? *

What medications is your pet currently on? (name of drug/mg/dose giving/how many times a day) *

Is your pet on any supplements (fish oil, Glucosamine, Chondroitin, CBD, aspirin)? (name of drug/mg/dose giving/how many times a day) *

How does your pet handle veterinary visits? *

Does your pet receive any anti-anxiety medications prior to veterinary visits? Anti-anxiety medications such as Gabapentin and/or Trazodone can help reduce stress & anxiety before veterinary visits. If your veterinarian has prescribed these, we recommend giving the doses the night before and the morning of your pet's consult and procedure. (If you have any further questions about this, feel free to give us a call). *

Is your pet allergic to any medications? If so, what? (Please list) *

Is your pet on monthly Heartworm Prevention? *

Yes: monthly, all year
Yes: seasonally (not all year)
No
Other

Other *

If on Heartworm Prevention, please list which one your pet is taking:

Is your pet on Flea Prevention? *

Yes: monthly, all year
Yes: seasonally (not all year)
No
Other

Other *

If on Flea Prevention, please list which one your pet is using?

Are you able to medicate your pet orally (by mouth)? *

Yes
No

If you can medicate your pet, do you prefer tablets or liquid medications? *

Tablets/capsules
Liquid medications
I cannot medicate my pet (if this is chosen, we will work out the best plan for your pet)

Has your pet had any major medical problems or previous surgeries? *

Does your pet have any history of issues with anesthesia? If so, please tell us about the issue (what happened/what was the concern). *

Has your pet had any unusual episodes of bleeding? *

Does your pet have any medical implants (ex. Orthopedic plates or screws, lens from cataract surgery, tracheal stent, ocular prosthesis, etc)? *

Does your pet have a history of airway surgery (ex. Brachycephalic airway surgery, debarking, etc)? *

Yes
No

Does your pet have a history of heart or lung disease? *

Does your pet have a history of seizures? *

No
Yes, however, they have never needed medications
Yes, and they are on medications for it

If your pet has a history of seizures, when was their last seizure?

Does your pet live indoors or outdoors? *

Indoors only
Indoors, but goes outside supervised to use the bathroom and play
Indoors, but goes outside unsupervised to use the bathroom and play
Outdoors only

Is your pet showing any signs of oral pain? (ex. Rubbing face with their paws or along the furniture, wanting to eat ~ but stopping because it is painful, eating slower than their usual, etc)? *

Is your pet having any coughing or sneezing? *

Yes: coughing
Yes: sneezing
No

Has your pet shown any signs of nasal discharge or bleeding from the mouth or nose? *

Yes: nasal discharge
Yes: bleeding from the mouth
Yes: bleeding from the nose
No

Has your pet had any facial swelling? *

Is there any dropping of the food from the mouth, or tilting the head while eating, or crying out and running away from the food bowl while eating? *

Other *

What is your pet's current diet and what is their feeding schedule (how many times per day and when to they get fed)? *

Has there been any appetite changes? *

Yes: increased appetite
Yes: decreased appetite
No

Does your pet have any food allergies or food intolerances? *

What treats does your pet get? *

Other *

How often does your pet get treats? *

Has your pet had any weight changes over the last 6 months? *

No
Yes: gained weight
Yes: lost weight

Has your pet had any vomiting or diarrhea? *

No
Yes: vomiting
Yes: diarrhea
Yes: vomiting and diarrhea

Has there been any increase or decrease in water consumption and/or urination? *

No
Yes: decreased consumption of water
Yes: increased consumption of water

Has there been any changes in your pet's activity level? *

No
Yes: less active
Yes: more active

What toys does your pet play with? *

Does your pet chew on rocks, sticks, wood, tennis balls, deer antlers, Nylabones, marrow bones, Himalayan yak chews, fences, or metal? *

The above mentioned objects are hard or inappropriate items that we do not want pets chewing on as these can cause tooth fractures and other issues with their teeth.

We don't want any pet chewing on something that you cannot "break" like a dog biscuit, indent with your fingernails (such as a kong or west paws toy), or that has some pliability/flexibility and you can bend it.

Does this make sense?

Yes
No

When was your pet's last professional dental cleaning? *

If your pet had a professional dental cleaning in the past, were dental x-rays performed? *

Yes
No
Unsure

Do you currently do any form of dental home care? *

Yes: Other *

How often to you provide dental home care? *

If you are not already doing so, would you be willing to brush your pet's teeth or do other forms of dental home care? *

No
Yes: Tooth brushing
Yes: Dental treats, water/food additives, dental diets, etc
N/A: I am already providing home care

Does your pet have any recent comprehensive labwork? *

If your pet has any heart disease or a heart murmur ~ has that been evaluated by a cardiologist in the last 3-6 months? *

Yes
Not applicable

If your pet has been evaluated by a cardiologist for a heart issue ~ let us know where we can obtain these records. Please upload

Click or drag a file to this area to upload.

Do you have any additional questions or concerns that you would like to discuss? Is there anything we have not asked that you feel is important for us to know? *

New Patient Visit Form