New Patient Form
Please complete the following information to the best of your ability. This is a safe space, so please don't hesitate to be open and honest about your concerns, and we will work through them together. The more details you provide, the more time we can spend discussing and addressing your pet's specific needs.
Client (Pet Owner) Information
Primary Contact's Name:
*
First Name
Last Name
Primary Contact's Pronoun(s):
He/Him
She/Her
They/Them
Primary Contact's Cell Phone Number:
*
Primary Contact's Work Phone Number:
Primary Contact's Home Phone Number:
Primary Contact's Email:
*
example@example.com
Primary Contact's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Contact's Name:
First Name
Last Name
Secondary Contact's Pronouns:
He/Him
She/Her
They/Them
Secondary Contact's Cell Phone Number:
Secondary Contact's Work Phone Number:
Secondary Contact's Home Phone Number:
Secondary Contact's Email:
example@example.com
Secondary Contact's Address: (If different from the Primary Contact's.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Your Pet's General Information
Pet Name:
*
Species:
*
Cat
Dog
Date of Birth:
*
(Best guess if unknown.)
Sex:
*
Female
Female Spayed
Male
Male Neutered
Breed:
*
For non-purebred cats, please indicate it is a short, medium, or long-haired cat.
Primary Veterinary Clinic or Hospital
Practice Name
Primary Veterinarian
Veterinarian Name
Does your pet have insurance?
*
Yes.
No.
If you have insurance, who is your Provider?
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Your Pet's General Medical History
How has your pet’s general health been at home?
*
Normal
Increased
Decreased
Eating / Appetite
Drinking / Water Intake
Urination
Defecation
Have you observed any of these health issues at home?
*
Yes
No
Coughing
Diarrhea
Itching
Skin Abnormalities
Vomiting
Does your pet have any known health conditions?
*
None
Autoimmune Disease
Cancer
Diabetes Mellitus
Kidney Disease
Liver Disease
Respiratory Disease
Thyroid Disease
Seizures
Other / Not listed
Does your pet have any known allergies to MEDICATIONS?
*
Yes
No
If yes, please list which medications.
Does your pet have any known FOOD allergies?
*
Yes
No
If yes, please list which ingredients.
Is your pet on a GRAIN-FREE pet food?
*
Yes
No
Is your pet on a PRESCRIPTION pet food?
*
Yes
No
If yes, what type of prescription pet food is your pet currently on?
Please list the BRAND (e.g., Hill's, Royal Canin, Purina) and formula (for example, i/d or gastrointestinal).
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Your Pet's Medication History
Is your pet currently taking any STEROID MEDICATIONS?
*
No
Prednisone or Prednisolone
Prednisolone / Trimeprazine (Temaril-P)
Methylprednisolone (Depo-Medrol; Medrol)
Other
Is your pet currently taking any non-steroidal anti-inflammatory drugs (NSAIDs)?
*
No
Acetaminophen (Tylenol)
Carprofen (Novox; Rimadyl; Rovera; Vetprofen)
Deracoxib (Deramaxx)
Firocoxib (Previcox)
Ketoprofen (Ketofen; Anafen)
Meloxicam (Metacam; Meloxidyl)
Piroxicam (Feldene)
Robenacoxib (Onsior)
Other
Please list ANY other medications or supplements your pet is currently taking at home:
Please indicate your preferences for oral medications types. We will do our best to consider this when sending medications home in the future.
Yes
No
Liquid Medications
Pill Medications (Capsules and/or Tablets)
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Medical Consent Form
Please tell us about your pet's ORAL HEALTH and/or ANESTHESIA concern(s):
*
Have you observed any of these potential signs of dental disease at home?
*
Yes
No
Bad Breath
Bleeding Gums
Broken Teeth
Changes in Chewing Behavior
Decreased Activity (i.e., Slowing Down or Acting Old)
Decreased Socialization Behaviors
Discolored Teeth
Dropping Food While Eating
Facial Swelling
Nasal Discharge
Non-Healing or Chronic Facial Wounds
Oral Pain
Poor Grooming or Poor Coat Quality
Resists or Reluctant to Accpet Head Petting
Sneezing
When was your pet's last professional (with a veterinarian) dental cleaning performed?
*
No professional dental cleaning performed yet
Within < 1 year ago
> 1 year ago
How often can you reasonably have your pet seen for professional dental cleanings under anesthesia? Once every…
*
6 months (if medically needed)
12 months
2 or more years
How concerned are you about tooth extractions?
*
No concerns about extracting teeth, extract any if and when needed.
Please save as many teeth as possible, only extract if absolutely necessary.
Avoid any extractions when there is a reasonable medical alternative available.
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Tooth brushing is the gold standard for oral hygiene, but not everyone has been doing or can do this kind of care at home. Please answer the following questions as appropriate.
*
Yes
No
Are you currently brushing your pet's teeth?
Are you able to brush your pet's teeth?
Are you interested in learning how to brush your pet's teeth?
If you have a DOG, what types of chew toys do you have at home for your pet? Please consider the following toy types: antlers, bones, hard plastic toys, nylon bones (e.g, Nylabone), rawhides, rope toys, rubber balls (e.g., Chuckit Balls), rubber chew toys (e.g., Kongs), and tennis balls.
Thank you for completing our "New Patient Form." We look forward to helping your pet and will reach out shortly to schedule your consultation.
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