Primary Owner
Additional Owner
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Species: CanineFeline
Sex Male NeuteredMaleFemaleFemale Spayed
Approximate date of birth
Please list the family veterinarians to whom you would like a summary letter forwarded, include Hospital and Veterinarian’s name
Please indicate the veterinarians we need to obtain records from; include Hospital and Veterinarian’s name
Reason for your visit
List of Major Medical Problems
List of current medications/doses/frequency
History of dental problems/treatment
Allergies to food or medication
Vaccinations of to date YesNo
Date of last blood work
Diet
Check any of the oral symptoms noted below bad breathloose teethgrowths on the gumdiscolored teethfailure to lose baby teethreluctance to chew hard itemsfractured/broken teethred or bleeding gumsother
Please check the toys/treats provided kongsbonesraw hidesfrisbeesrope toysdog biscuitsice cubestennis ballsgreeniesplush/squeakynylon toysantlersother
Please indicate your pet's current dental home care (if any) and the frequency it is provided (examples - brushing, rinse, dental diet, dental chews, water additive)
I hereby authorize the veterinary team of Animal Dental Specialists (ADS) to examine, prescribe for, and treat my pet.
I understand that I will receive a summary of the care provided in order to ensure that my pet's care can be continued without interruption.
I also understand that the identification of a referring veterinarian by me to be my authorization for ADS to obtain medical records, as well as release records and information to that veterinarian. Case information, medical images, photos and/or videos of my pet(s) may be used in teaching forums, continuing education, hospital web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained.
Payment is due as services are rendered. The balance will be due upon discharge from the hospital. You may pay by cash, Care Credit, or accepted credit cards.
In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance.
I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.
I have read and agree to the treatment authorization.
I have also read and accept the financial obligations.
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