Animal Dental Clinic of Pittsburgh

9117 Marshall Road
Cranberry Township, Pennsylvan 16066

(724)475-3566

www.animaldentalclinicpgh.com

 

Dental History Form

 

Clients: Please fill out the form below and submit the form electronically or click HERE to print a PDF version and email it to adcreferrals@animaldentalclinicpgh.com thank you.

Dental History Form

Date (required) :
Have you been to our clinic before? (required)

Yes
No


Patient Name: (required)

Acquired From: (required)

Breeder
Shelter
Rescue
Other


If acquired from other, please explain:

How long has the animal been with you? (required)

Is this a show animal or working animal? (required)

(For Cats) Living Situation:

Indoor
Outdoor
Indoor & Outdoor


(For Cats) FIV Status:

Negative
Positive


(For Cats) FeLV Status:

Negative
Positive


Please list dietary specifics: (Dry Food, Wet food, Treats, etc).. (required)

Allergies or Diet Restrictions? (Please explain, if yes). (required)

Any difficulty eating? (Please explain, if yes). (required)

Current Medications (Name, dose and frequency): (required)

Does your pet play with any toys?

Does your pet chew on any hard objects?

Previous dental procedures? (required)

Yes
No


If yes, please specifiy the date of your pets last dental procedure: :
Anesthetic Complications:

Current home dental care plan and products: (required)

Any other Episodes of general anesthesia?

Health Problems:

Seizure History (required)

Yes
No


Vomiting: (required)

Yes
No


Diarrhea: (required)

Yes
No


Coughing: (required)

Yes
No


Sneezing: (required)

Yes
No


*Presenting Complaint: (required)

Contact phone number(s) for procedure day: (required)
Phone TypePhone Number (required)
Please verify your email address: (required) :

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