Dentistry & Oral Surgery Patient - Gulf Coast Veterinary Specialists

Today's Date*

Patient Name*

Species*

Breed*

Age*

Sex*

Owner Information

Name*

First Last

Best Contact Number*

Email*

Referring Clinic*

Veterinarian Name*

What are we seeing your pet for?*

What symptoms have you observed at home?*

How long have the symptoms been present?*

Did the symptoms start suddenly?*

How would you describe the symptoms?

Progressing
Staying the same
Improving
Unsure

Is your pet experiencing trouble eating and/or drinking? Please explain.*

Does your pet exhibit any of the following? If so, please select all that apply.

Excessive sneezing
Excessive drooling
Dropping food from the mouth
Pawing at the mouth
Lip smacking
Nasal discharge

Has your pet's appetite changed recently?*

What kind of diet (hard or soft) do you feed your pet?*

Does your pet chew on toys or bones? If so, what type and how often?*

Do you provide any of the dental homecare listed below?

Tooth brushing
Dental chews/treats
Water additive
OraVet
None

Has your pet ever received a professional dental cleaning under anesthesia?*

Yes
No

Has your pet ever had any teeth extracted?*

Yes
No
Unsure

Has your pet ever received other advanced dental procedures (root canal, etc.)? Please Explain.

Is your pet otherwise normal or are there any other medical problems we need to know about? (Diabetes, heart disease, history of seizures, history of pancreatitis, etc.)*

Is your pet currently on any medications to treat the condition we are evaluating today?*

Yes
No

Have medications been previously used that were NOT successful?

Please list ALL medications your pet currently takes for UNRELATED problems. If none, please type NONE.*

Does your pet have any medication reactions or food allergies? If none, please type NONE.

Do you have other pets?*

Yes
No

Please list all clinics/veterinarians that your pet has seen (including any out of town clinics, emergency clinics, or specialty practices such as a neurologist, cardiologist, dermatologist, etc.).*

IT IS IMPERATIVE THAT WE HAVE THIS INFORMATION IN ORDER TO PROVIDE THE BEST PATIENT CARE POSSIBLE.

Do you have pet insurance?*

Yes
No

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