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| 780-570-9999
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Menu
Home
About Us
Contact
Departments
Cardiology
Dentistry & Oral Surgery
Ophthalmology
Diagnostic Imaging
Surgery
Neurology
Avian and Exotics
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
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Patient Information
Pet Name
*
Pet Age
*
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
*
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)
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
