New Client Questionnaire - Dental Patient
Patient Name
Owner's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Name of local vet clinic
If your pet is insured, which company do you use?
What is your pet's policy number?
General Health
What is the main problem?
At what age was the condition first noticed?
Has there been any?
Vomiting
Diarrhoea
Mucous stools
Lethargy
Increased water intake
Increased appetite
Weight gain
Weight loss
Weakness
Does your pet have any other illness, if so please specify what medicines are being prescribed?
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Oral History
Does your pet:
Rub at the face
Fractured Teeth
Oral pain
Head shake
Bleeding gums
Eye discharge
Nasal Discharge
Facial Swelling
Sneeze
Off Food
Tooth loss
Change in chewing or eating habbits
Other
Other (more info if required)
Has your pet had previous Dental treatment?
Yes
No
Date of last professional Dental treatment.
Medication
Please give the name and dose of medication/s given
Current Medications
Name / Dose & Date Last Given
Is your Pet Vaccinated?
Yes
No
When was the last vaccine?
Is your Pet on heartworm treatment?
Yes
No
What type of heartworm treatment is being used?
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Oral Homecare
Do you brush your pets teeth?
Yes
No
How often do you brush your pets teeth?
Do you perform other oral homecare i.e dental treats
Diet
What do you normally feed your pet?
Cans
Dry
Meat
Table scraps
What is the brand of food?
Which types of meat do you feed your pet?
Any supplements?
(e.g. vitamins, minerals, fatty acids, glucosamine etc)
What do you give for snacks and treats?
Have you ever fed a special diet?
Yes
No
If yes, what diet?
Do you consent to us posting images of your pet on social media?
*
Does your pet have a social media account?
What is your pets social media account name?
example@example.com
If your pet is insured, which company do you use?
*
What is your pet's policy number?
*
Please tell us how you found us:
*
Veterinary referral
Online search (Google, etc.)
Social media
Word of mouth
Returning client
Other
Submit
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