Primary Owner
Primary owner name
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First Name
Last 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.
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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.
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Alternate phone number
Mailing address
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Street Address
Street Address Line 2
City
State / 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?
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Second owner
Pet Details
Pet name
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Species
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Please Select
Dog
Cat
Breed
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Estimated weight (pounds)
Birthdate or estimate
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-
Month
-
Day
Year
Date
Reproductive status
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Please Select
Male neutered
Female spayed
Male intact
Female intact
Color
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Medical History
What is your main concern with your pet's dental and oral health?
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Please Select
broken tooth
bad breath/periodontal disease
oral mass/swelling
difficulty eating
malocclusion/abnormal bite
routine dental care
other concern
What is your primary reason for seeking a dental specialist for your pet instead of your primary care veterinarian?
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Which of the following signs of discomfort is your pet displaying?
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Preference for soft or wet food
Pawing at face
Self-grooming less
Messy eating, dropping food
Reluctance to play with toys
Change in chewing habits
Lethargy
Reclusive and less interactive
Refusal to allow head/face touching
Drooling
None, I have not noticed signs of discomfort
Provide a brief description of your pets dental history and previous professional dental care:
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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
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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.
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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?
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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.
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My pet does not show any aggression towards dogs or cats.
My pet is NOT friendly towards dogs or cats and should be isolated during their visit. (Please keep your pet in the car upon arrival and call us so we can help keep everyone safe).
My pet is NOT friendly with CATS. Please ensure Oscar is locked in a separate room or kennel during our visit.
My pet is NOT friendly with DOGS and should be isolated during their visit.
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?
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No
Yes
Has any veterinarian ever needed or recommended sedation for your pet during an exam or prior to visits?
Please Select
No
Yes (please contact us to discuss further)
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)
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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?
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Our medical record will be forwarded to your primary care veterinarian. Indicate where we should send our report.
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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.
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Veterinary Hospital of Record
Contact Number
1
2
3
Upload any photos, proof of vaccination, or records that you have available:
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How did you hear about us?
*
Please Select
Primary care veterinarian referral
Friend or family member
Google search
Facebook
Other online search
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 $160. 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 20 minutes late, will be billed a non-refundable $150 fee.
Type your initials here to indicate that you understand and agree to our financial policies.
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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.
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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.
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Insurance Provider
Policy Number
Should be Empty: