Premier Pet Dentistry Registration Form

You must complete all sections and sign the finalized form to complete your registration.

Please complete all fields with as much detail as possible. This allows us to expedite your visit and ensure a smooth process. Once completed, you will receive the following image with a green check mark to acknowledge that the form is complete, as well as a copy to your own email. YOU MUST SIGN TO SUBMIT THE FORM. If you do NOT see the following image that says "Thank You!", then you have an incomplete field that must be resolved before you can SIGN and SUBMIT. If you do NOT receive an emailed copy, then we have not received your form.

Primary owner name

First NameLast Name
E-mail: You will not receive solicitations from us. We are a paperless practice with all pre and post anesthetic instructions, invoices, and receipts sent through email. Provide the best email to receive these written communications.
example@example.com
Mobile phone number: communications, visit reminders, and surgical updates are provided through text messaging. Please provide the best number to text during your pets visit. By checking this box you agree to receive recurring messages from Premier Pet Dentistry and Oral Surgery, Reply STOP to Opt out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All OPT-IN requests include text messaging originator opt-in data and consent; this information will not be shared with third parties.
Format: (000) 000-0000.
Do you consent to SMS messaging?
Alternate phone number
Format: (000) 000-0000.
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your pets primary caretaker must be present for the consultation to meet with the Doctor. If someone else would be bringing your pet, please contact us to reschedule your appointment to a more appropriate time when you can be present. Who is the primary caretaker who will be present for the visit?

Pet name
Species
Breed
Estimated weight (pounds)
Birthdate or estimate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reproductive status
Color

If you have insurance for your pet, provide the information below. If you are making a claim, you will need to first file a claim and then forward us the claim information for record requests to be processed and submitted to your insurance. Indicate N/A if you do not have insurance for your pet.

Rows	Insurance Provider	Policy Number

What is your main concern with your pet's dental and oral health?
Please help us understand your concern and reason for seeking a Dental Specialist for your pet instead of treatment with your primary care veterinarian?

Other
If selecting 'other', please describe your concerns or indicate N/A
Which of the following signs of discomfort is your pet displaying?
Provide a brief description of your pets dental history and previous professional dental care:
What do you provide at home for dental care? Please list all products, bones, chews, and their frequency.
Does your pet have any previous serious illnesses, chronic conditions or general health concerns? Please provide as much detail as possible to help us prepare for anesthesia
Please tell us about your pets food. List the type (kibble vs canned etc), amount, and frequency of feeding. Please describe any unique or unusual eating habits you have noticed.
Describe your pet's temperament and reaction to being handled/examined. Is there anything special we should know to help keep your pet comfortable during their visit?
Premier Pet Dentistry has a cat (named Oscar) that lives in the office and has free range of the facility. He is on a monthly flea/parasite control, free of infectious disease, and has no teeth to bite or defend himself. You are responsible for controlling your pet (dogs on a leash and cats in a carrier). If your pet has an altercation with Oscar or any other patient during their visit, you will be held liable and financially responsible for all costs for care. To keep Oscar and all patients safe, let us know how your pet acts around other animals.
We must be able to examine your pet's mouth safely. This may require medication. Has your pet ever bitten, "nipped", required a muzzle or shown aggression towards any person?
Has any veterinarian ever needed or recommended sedation for your pet during an exam or prior to visits?

Please list the medications and supplements your pet is receiving now, has previously had for their current condition, or has received within the last month. (or indicate none)

Rows	Medication	Dosage	Frequency
1
2
3

We require proof of recent Rabies vaccination, adequate titer within the last 3 years, or documented waiver from your primary care. What is the date of your pets most recent rabies vaccine?

Our medical record will be forwarded to your primary care veterinarian. Indicate where we should send our report.

Rows	Current Primary Care Veterinary Facility	Contact Number
1

We will need medical records, bloodwork, and x-rays for ANY dental care your pet has received. List ALL additional veterinarians who have your pets dental or surgical medical records. If we have not received these records at least 2 days in advance of your pets visit, it may be cancelled.

Rows	Veterinary Hospital of Record	Contact Number
1
2
3

Upload any photos, proof of vaccination, or records that you have available:

Cancelof
How did you hear about us?
Is there anything else you would like us to know about you or your pet to prepare for your visit?
Fees

Our new patient consultation fee is $190. Bloodwork or other pre-anesthetic diagnostics are an additional cost dependent upon your pet's specific needs. Payment is due in full at the time of service. Anesthetic procedures require a deposit when your pet is admitted. We accept all major credit cards, Care Credit, and cash. We do not accept ANY checks. Consultations that are cancelled with less than 2 business days notice, missed, or arrival more than 10 minutes late, will be billed a non-refundable $75 fee. Procedure cancellations with less than 2 business days notice, missed, or admitted more than 15 minutes late, will be billed a non-refundable $150 fee.
Type your initials here to indicate that you understand and agree to our financial and cancellation policies.
Consent and Terms

I, the undersigned, affirm that I am the legal owner or authorized representative responsible for the pet listed. I assume financial responsibility for all charges incurred for services or missed appointment fees and agree to pay all such charges at the time they are rendered. I give permission for Premier Pet Dentistry and Oral Surgery to use anonymized photographs or diagnostic images for educational and marketing purposes.
Signature
Should be Empty:

You must complete all sections and sign the finalized form to complete your registration.

Fees

Consent and Terms