New Patient

Date of Birth

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

Never Had Lab Work/Not Sure

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 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 check the toys/treats provided
kongsbonesraw hidesfrisbeesrope toysdog biscuitsice cubestennis ballsgreeniesplush/squeakynylon toysantlersother

Diet

I hereby authorize the veterinary team of Animal Dental Services (“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.

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.