Consultation with Procedure Check-In
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 Name:
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First Name
Last Name
Secondary Contact Name:
First Name
Last Name
My preferred phone number for contact today is:
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Please enter a valid phone number.
Format: (000) 000-0000.
If I cannot be reached at my primary phone number, please contact me at my secondary phone number:
Format: (000) 000-0000.
If we are unable to reach you during the procedure to review the treatment plan or any changes, what would you prefer that we do?
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Move forward with patient care, staying within the original estimate range.
Recover my pet from anesthesia and do not proceed with additional treatment.
Your Pet's Information
Pet Name:
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Species:
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Cat
Dog
Your Pet's General Medical History
How has your pet’s general health been at home?
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Rows
Normal
Increased
Decreased
Eating / Appetite
Drinking / Water Intake
Urination
Defecation
Have you observed any of these health issues at home?
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Rows
Yes
No
Coughing
Diarrhea
Episodes of Collapse
Exercise Intolerance (e.g., Prematurely Tired with Routine Activity)
Itching
Seizures
Skin Abnormalities
Vomiting
Weakness
Have you observed any of these potential signs of dental disease at home?
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Rows
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
Drooling
Dropping Food While Eating
Facial Swelling
Nasal Discharge
Non-Healing, Chronic, or Recurrent Facial Wounds
Oral Pain
Poor Grooming or Poor Coat Quality
Resists or Reluctant to Accpet Head Petting
Sneezing
Your Pet's Medication History
Did your pet take any of the following medications LAST NIGHT?
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Acepromazine
Gabapentin
Trazodone
Maropitant (Cerenia)
Blood Pressure Medication (e.g., Amlodipine, Benazepril, or Enalapril)
Non-Steroidal Anti-Inflammatory Medication (NSAID; e.g., Carprofen, Grapiprant, or Meloxicam)
Steroid Medication (e.g., Prednisone, Prednisolone, Temaril-P)
None administered
Did your pet take any of the following medications THIS MORNING?
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Acepromazine
Gabapentin
Trazodone
Maropitant (Cerenia)
Blood Pressure Medication (e.g., Amlodipine, Benazepril, or Enalapril)
Non-Steroidal Anti-Inflammatory Medication (NSAID; e.g., Carprofen, Grapiprant, or Meloxicam)
Steroid Medication (e.g., Prednisone, Prednisolone, Temaril-P)
None administered
Does your pet have any known allergies to MEDICATIONS?
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Yes
No
If yes, please list which medications.
Is your pet currently taking any STEROID MEDICATIONS?
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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)?
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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? When were they last administered?
(Please be as specific as possible.)
Please indicate your preferences for oral medications types. We will do our best to consider this when sending medications home in the future.
Rows
Yes
No
Liquid Medications
Pill Medications (Capsules and/or Tablets)
Your Pet's Dietary History
When did you feed your pet last?
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Last Night
This Morning
Is your pet on a PRESCRIPTION pet food?
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Yes
No
Does your pet have any known FOOD allergies?
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Yes
No
If yes, please list which ingredients.
Client Consent & Financial Responsibility Agreement
I attest that I am the legal owner or authorized responsible party for all animals presented and accept full financial responsibility for all charges incurred during their care. I acknowledge that I have been provided with a good faith estimate and understand that actual charges may vary due to the inherent variability of medical treatment. Houndstooth Veterinary Dentistry & Oral Surgery will make every reasonable effort to keep me informed of significant changes to the estimate as they occur.I understand and agree that payment in full is due upon completion of services, regardless of treatment outcome, and that charges for services rendered are not contingent upon the animal’s recovery or survival. I further agree that no refunds, chargebacks, or payment reversals shall be initiated for services properly rendered and documented.
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I have read, understood, and accept the risks outlined above, and I agree to the terms stated.
I consent to the release of my animal’s medical information to my referring veterinary clinic and authorize the use of my animal’s medical information, including history, clinical images, and radiographs, for teaching or scientific educational purposes.
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I have read, understood, and accept the risks outlined above, and I agree to the terms stated.
Surgical and anesthesia risks can include, but are not limited to adverse reactions to medications, changes in vital parameters (e.g., heart rate, blood pressure, or respiration, and body temperature), bleeding, blood clot formation, surgical site Infection, delayed wound healing, and/or unexpected complications due to pre-existing or undiagnosed conditions. I acknowledge that these risks cannot be completely predicted.
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I have read, understood, and accept the risks outlined above, and I agree to the terms stated.
To support accurate and efficient medical records, we may use audio recording during your pet’s consultation and exam.
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I have read, understood, and accept what is outlined above.
Signature
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*
Client Name
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