Please fill out this form if you have an upcoming appointment or wish to make one. If you do not currently have a scheduled appointment you may still fill out this form, however, please call us to confirm a consultation date and time.Owner's Name* Owner's First Name Owner's Last Name Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Secondary Phone*Email* Referring Veterinarian* Hospital* Place of Employment Patient's Name* Name Species* Canine Feline Breed* Color* DOB/Age* Sex* Male-neutered Female-spayed Male-Intact Female-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?* Yes No 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?* Yes No 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?* Is there anything else you'd like us to know?CommentsThis field is for validation purposes and should be left unchanged.
