EMERGENCY
| 780-570-9999
Submit a Referral
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Menu
Home
About Us
Careers
Contact
Departments
Avian and Exotics
Cardiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Orthopedic Foundation for Animals (OFA)
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Dentistry & Oral Surgery Questionnaire
Dentistry & Oral Surgery Questionnaire
Step
1
of
4
25%
Patient Information
Pet Name
*
Pet Age
*
Is your dog a working-dog?
*
Yes
No
What type of work?
*
Please explain
Client Information
Owner First Name
*
Owner Last Name
*
Spouse (or second contact) First Name
Spouse (or second contact) Last Name
Owner Phone Number
*
Owner (secondary) Phone Number
Referring Veterinarian Name
*
Referring Veterinary Practice
*
Do you have medical insurance for your pet?
*
Yes
No
What company is it with?
*
Medical History
How long have you owned your pet?
*
Is your pet up-to-date on vaccines?
Yes
No
What kind of food is your pet eating?
*
Does your pet prefer wet or dry food?
*
Wet
Dry
Is your pet on any medications?
*
Yes
No
Medications
Please provide the drug names, dosages, and frequency (if known)
Hidden
Does your pet have any important medical or surgery history?
*
Yes
No
Medical/Surgery history
*
Please elaborate
Any travel history outside of Alberta?
*
Yes
No
Travel history
*
Where?
Are there any kids at home?
*
Yes
No
Are there any pets at home?
*
Yes
No
Has your pet had any previous dentistry/oral surgery procedures?
*
Yes
No
Previous dentristry/oral surgery procedures
*
Please elaborate on treatment
Do you offer any oral treats, chews, toys, oral rinses?
*
Yes
No
Oral treats, chews, toys, oral rinses
*
Please elaborate
Do you brush your pet's teeth?
*
Yes
No
Brushing frequency
*
Please elaborate on frequency
How interested are you in learning more about tooth brushing?
*
Very
Somewhat
Not interested
Medical Questions
Does your pet have any concerns with eating?
*
Yes
No
Eating concerns
*
Please elaborate
Does your pet have any concerns with drinking?
*
Yes
No
Drinking concerns
*
Please elaborate
Does your pet have any concerns with vomiting?
*
Yes
No
Vomiting concerns
*
Please elaborate
Does your pet have any concerns with diarrhea?
*
Yes
No
Diarrhea concerns
*
Please elaborate
Does your pet have any concerns with constipation?
*
Yes
No
Constipation concerns
*
Please elaborate
Does your pet have any concerns with breathing issues?
*
Yes
No
Breathing issues concerns
*
Please elaborate
Does your pet have any concerns with sneezing?
*
Yes
No
Sneezing concerns
*
Please elaborate
Does your pet have any concerns with coughing?
*
Yes
No
Coughing concerns
*
Please elaborate
Does your pet have any concerns with exercise intolerance and/or weakness?
*
Yes
No
Exercise intolerance and/or weakness concerns
*
Please elaborate
Does your pet have any concerns with urination?
*
Yes
No
Urination concerns
*
Please elaborate
Please check the box, if there are any concerns/observations that apply to your pet
Oral pain
Bloody saliva
Drooling
Foul breath
Tartar/plaque
Hard food preference
Soft food preference
Dropping food
Chewing on one side of the mouth
Swallowing food without chewing
Change in demeanor/energy level
Jaw and tooth chatter
Tooth-on-tooth contact
Sneezing
Nasal discharge
Nasal bleeding
Reduced grooming
Head shyness
Facial swelling
