Address *

Street Address

ZIP / Postal Code

Primary Phone *

Secondary Phone *

Email *

Place of Employment

Patient's Name *

Name

Species *
CanineFeline

Breed *

Color *

DOB/Age *

Sex *
Male-neuteredFemale-spayedMale-IntactFemale-Intact

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

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

What is the reason for your visit? *

Has your pet had any facial swelling, sneezing, or nasal discharge recently? *
YesNo

If yes, please describe: *

How were you referred to the Center?

Is your pet taking ANY medications (including supplements, aspirin, heartworm preventative)? If so, please list them *

All patients regardless of age or health status are required to have pre-anesthetic blood work (CBC and full chemistry panel) within 30 days of anesthesia. All patients with oral masses need to have recent three-view chest x-rays. We can perform blood work at our facility but we do not have the ability to do chest x-rays. Please list the recent diagnostic tests your pet has had and the date performed. *

All patients are required by law to be up to date on Rabies vaccination. Please list the date of last rabies vaccination *

Has your pet had previous dental procedures? *
YesNo

If yes, please explain

Please list any anesthesia and surgery history and/or complications *

Any unusual episodes of bleeding? *

Does your pet have any history of a heart murmur? If yes, have they been evaluated by a cardiologist? *

Current diet - please list brand and texture (kibble or soft food) *

What kind of chews does your pet like ? *

What kind of toys do they play with? *

Are you currently brushing your pet’s teeth? If so, how often? *

What dental products are you using at home? *

How does your pet handle veterinary visits? *

Do you give any anti-anxiety medications prior to veterinary visits? Anti- anxiety medications such as gabapentin and trazadone can really help reduce stress before veterinary visits. We recommend giving a dose the night before and the morning of your procedure. Please call us for further instructions *

Is there anything else you'd like us to know?