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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Landline phone number
Work/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
*
Please Select
Male neutered
Female spayed
Male intact
Female intact
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.
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Insurance Provider
Policy Number
Medical History
What is your main concern with your pet's dental and oral health?
*
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 that could impact 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 unusual eating habits you have noticed.
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Please describe your pet's temperament and reaction to being handled/examined. If your pet has ever required medication or sedation before veterinary visits, please contact us prior to your appointment
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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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We must obtain your pets complete medical records from all veterinarians who have provided dentistry within your pet's lifetime, or any other care within the last 2 years. If we have not received medical records 2 business days prior to your visit, it will be cancelled. Where can we contact to request medical records:
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Veterinary Hospital of Record
Contact Number
1
2
3
Our medical record will be forwarded to your primary care veterinarian. Indicate where we should send our report.
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Primary Care Veterinary Facility
Contact Number
1
Upload any photos, proof of vaccination, or records 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
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 checks. Consultations that are cancelled with less than 2 business days notice, missed, or 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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