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—Please choose an option—MaleMale NeuteredFemaleFemale Spayed
Approximate date of birth
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.
Reason for your visit
List of Major Medical Problems
List of current medications/doses/frequency
History of dental problems/treatment
Has your pet had an anesthetized dental cleaning procedure before?
Date of last cleaning procedure
Allergies to food or medication
Date of Last Rabies Vaccine
Date of last blood work
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.)
Please attach an image of your pet.
*Accepted files: .png, .jpg, .gif
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.
I authorize Animal Dental Specialists of Nevada to use case information, photos, videos, images, and records from my pet's treatment for educational, advertising, or other promotional purposes. I also understand that my client confidentiality will be strictly maintained.
Payment is due at the time services are rendered. A deposit may be required at the time of scheduling a treatment procedure. Payment may be made by cash, check, accepted credit cards, or pre-authorized payment services (Care Credit). Please advise us in advance if you have any questions or concerns regarding our payment policy.
I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.
By signing this document, I ackowledge that I (the owner or agent) am financially responsible for all charges related to documented patient(s) on my record, and I understand the hospital's financial policy. I also acknowledge that the above information and statements are accurate.
My name typed in the box below will be accepted as a legal electronic signature
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