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Home
About Us
Services
Referring a Client
Forms
Continuing Education
Contact
Privacy Policy
Refer a Client
Home
About Us
Services
Referring a Client
Forms
Continuing Education
Contact
Privacy Policy
Menu
Home
About Us
Services
Referring a Client
Forms
Continuing Education
Contact
Privacy Policy
Needing a consultation?
Please fill out the form below.
Owner Information
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Animal Information
Pet Name
(Required)
Age
(Required)
(please specify if age is in years or month)
in YEARS
in MONTHS
Gender
M
M(n)
F
F(n)
Species / Breed
(Required)
General Medical History
Date of last physical exam
MM slash DD slash YYYY
Recent blodwork?
Yes
No
Recent thoracic (chest) radiographs?
Yes
No
Please list past medical conditions.
History of heart disease?
Yes
No
History of kidney disease?
Yes
No
History of cancer?
Yes
No
History of diabetes mellitus?
Yes
No
Please list all current medications and supplements, along with their dose, frequency, and last time given.
Known allergies?
Yes
No
Has your dog / cat ever had a blood transfusion before?
Yes
No
Don't know
Has your pet ever had surgery before?
Yes
No
Dental History
Do you do any homecare (regular tooth brushing)?
Yes
No
Do you use any dental supplements (water additives, etc.)?
Yes
No
Have you noted any (select all that apply)?
Bad Breath
Difficulty chewing or eating
Lost teeth
Facial swelling
Nasal discharge
Coughing or sneezing
Difficulty picking things up with their mouth
Behaviour changes (reluctance to play, etc.)
Changes in appetite (decrease / increase)
Painful around mouth / face
Broken or chipped teeth
Oral fissures (on gums, tongue, lips, etc.)
Has your dog / cat ever had a professional dental cleaning under general anesthesia?
Yes
No
Has your pet even had oral surgery?
Yes
No
Do you have any specific questions or concerns? Please describe.
I consent to the use and storage of my information in accordance with the terms and conditions detailed in the privacy statement.
I consent to the use and storage of my information in accordance with the terms and conditions detailed in the
privacy statement
.
I agree to the terms and conditions
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