Center For Veterinary Dentistry And Oral Surgery

9041 Gaither Road, Gaithersburg, MD 20877 ~ 301-990-9460

Patient Information Form

Referring Veterinarian*

Hospital*

Owner's First Name*

Owner's Last Name*

Street Address*

City*

State*

Zip Code*

Primary Phone*

Secondary Phone

Email*

Place of Employment

Patient's Name*

Species*

Canine

Feline

Breed*

Color*

DOB/Age*

Sex*

Male - Neutered

Male - Not Neutered

Female - Spayed

Female - Not Spayed

Is your pet allergic to any medication? If so, what? (Please list)*

What is the reason for your visit?*

Has your pet had any facial swelling, sneezing, or nasal discharge recently?*

Yes

No

If yes, please describe:*

How were you referred to the Center?

Is your pet taking ANY medications (including supplements, aspirin, heartworm preventative)? If so, please list them*

Recent blood work or other diagnostic tests? If yes, please list*

Has your pet had previous dental procedures?*

Yes

No

If yes, please explain

Please list any anesthesia and surgery history and/or complications*

Any unusual episodes of bleeding?*

Does your pet have any history of a heart murmur? If yes, have they been evaluated by a cardiologist?*

Current diet - please list brand and texture (kibble or soft food)*

Is there anything else you'd like us to know?

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