Please call the office to set up a consultation prior to completing this form

Thank you so much for taking the time to fill the medical information for your pet. The information you provide below along with your pet’s medical records from your referring veterinarian office will help us to facilitate a thorough oral examination and provide you with our recommendations based on these findings.

Date Completed:*

Owners Name:*

First Last

Owners Email:*

Pet's Name:*

Best Phone to reach you if we have further questions prior to your pet's visit:*

What is the reason your pet was referred to Oregon Veterinary Dental Specialists?*

Who is your primary care veterinarian and at which hospital are they referring from?*

Does your pet see any veterinary specialist for advanced veterinary care?*

Yes

If yes please list all specialists your pet has seen or still under their care.

When did you first notice your pet’s dental/oral condition?*

Is your pet showing any signs of pain or discomfort? (pawing at face, rubbing face, only chewing on one side of the face, dropping food, etc.)*

Yes

If yes please describe what you have noticed.

Is your pet on pain medications or antibiotics for this dental condition.*

Yes

If Yes Have those medications helped?

Do you currently have a dental homecare regiment for your pet? If so, please explain what you are doing and what products you use.*

How many dental cleaning procedures has your pet had over its lifetime under general anesthesia?*

When was the most recent dental cleaning procedure?*

Did your pet have any dental treatments (surgical extractions) at that time?*

Yes

Is your pet eating and drinking well?*

Yes

If "No" above what are you observing?

What does your pet eat? (check all that apply)*

Kibble

Wet Food

Raw Food

Grain Free

Please tell us what brands of food your pet eats.*

Does your pet have any food allergies?*

Yes

If so, please explain what they are allergic to and what diet they are currently eating.

Does your pet play with toys?*

Yes

If Yes what kind of toys does he/she enjoy playing with or chewing on?

Has your pet recently had any unusual Coughing, Sneezing or Vomiting?*

Yes

If "yes" to any of the above symptoms, please describe for how long and if they have recently been treated for it?

Has your pet recently had any Diarrhea?*

Yes

If yes, is your pet currently being seen for this condition?

Yes

Please list all current medications & supplements: (Please include the dose)*

Does your pet have any chronic health conditions such as a heart murmur, Thyroid disease, kidney disease, autoimmune disease, diabetes etc.?*

Yes

If yes please list the conditions.

When was your pet’s last comprehensive blood panel completed?*

If it was done at a clinic other than your primary care clinic, please list the name of the clinic so we can request a copy of those results.

You must click on the Submit button below after you verify the Captcha code.

When you submit this form, there will be a link on the next page to fill out our New Client Form if you have not done so already. They must both be submitted to us prior to your initial scheduled appointment. Thank You

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Pre-Consultation Questionnaire

Please call the office to set up a consultation prior to completing this form