Dental Special Intake
Please provide the following information on you and your pet so we can make sure to give you both the best possible care!
OWNER INFORMATION
Full Name
*
Today's Date
-
Year
-
Month
Day
Date
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Apt/Unit
City
State / Province
Postal / Zip Code
Address
*
Patient Details
Pet Name
*
Special diet or prescription food?
*
Approximate Birthdate
*
Approximate Weight
*
Male or Female
*
Species/Breed
*
Is your pet anxious/aggressive?
*
Is your pet spayed or neutered?
*
Please Select
Yes
No
I don't know
HEALTH CONCERNS/SYMPTOMS
Special notes or concerns you would like to address during the appointment
*
Describe, if any, your pet's known health conditions
I understand that my pet will undergo sedation and must be fasting (no food or water) for 10 hours prior to dental cleaning
*
Initial
Is your Pet on any medication?
*
Yes
No
What is the name of the medication, the dosage, and how long have they been on it?
*
Would you like to add
Blood work
Flea meds
Deworming
Anal gland expression
Grooming (not always possible, but we'll try to accomodate!)
Please describe the grooming you would like (bath, haircut, haircut-length, etc.)
Groomers will do their best to accommodate, however results are not guaranteed.
Please provide a photo example of the type of haircut you would like for your pet.
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Are the vaccines up to date? (If so, please upload below)
*
Yes
No
If not up to date, which vaccines are we updating today? (Rabies vax required for dogs)
*
Rabies (required for dogs if not already up to date)
Parvovirus/Coronavirus
Distemper/Leptospirosis
Bordetella
Other
Please upload rabies vaccination records (if your pet is a dog)
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Rabies vaccination is required for dogs to re-enter to the US. If you have a dog riding with us and you don't have a rabies certificate, we can have the vaccine updated during their appointment.
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Lastly, please give us a recent picture of your pet!
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(619) 782-4747 | Info@MexiVetExpress.com | www.MexiVetExpress.com
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