New Patient

Please list the family veterinarians to whom you would like a summary letters forwarded. Include Hospital Name

Please indicate the veterinarians we need to obtain records from. Include Hospital Name.

Has your pet had an anesthetized dental cleaning procedure before?
YesNo

Diet

Check any of the oral symptoms noted below
bad breathloose teethgrowth(s) on the mouthdiscolored teethfailure to lose baby teethreluctance to chew hard itemsfractured/broken teethred or bleeding gumsother

Please check the toys/treats provided
rubber chew toysreal bonesrawhidesrope toysdog biscuitsice cubestennis ballsGreenies or other dental chewsplush/squeakyhard plastic/nylon bones or toysantlers/horns/hoovesother

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 Specialist of Nevada to examine, prescribe for, and treat my pet. The treatment plan, expectations, and anticipated cost, will be discussed prior to initiating any treatment. Modifications of the treatment plan will be discussed when necessary.

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 authorize Animal Dental Specialists of Nevada to request medical records from the veterinary provider listed above and other providers that may have relevant records. I also authorize Animal Dental Specialists of Nevada to release records to the provider that I listed above, and to other veterinary hospitals that legally request them.

Do you authorize Animal Dental Specialists of Nevada to use case information, photos, videos, images, and records from your pet's treatment for educational, advertising, or other promotional purposes (including social media, i.e. Facebook and Instagram)? I also understand that my client confidentiality will be strictly maintained.
I authorizeI do not authorize

I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.