Client Name *

Client Phone Number *

Client Email Address *

Referring Veterinarians Name *

Patient Name *

Patient DOB *

Species (Canine or Feline only) *

Canine
Feline

Breed *

Color *

Weight (kgs) *

Stage of Periodontal Disease *

1
2
3
4

Observed fractures *

Yes
No

Observed resorptive lesions *

Yes
No

Has this patient had previous dental procedures? *

Yes
No

Any other dental observations or notes regarding this patient

Has the client been educated about the possibility of dental extractions? *

Yes
No

Does the patient have a history of any of the following conditions? *

Heart murmur/known cardiac disease
Seizure
Behavioural issues/considerations
Anesthetic complications/considerations

Does the patient have any other conditions/diagnoses? If so, please list them below

Is the patient on any current medications? If so, please list them below

Is the client aware that we require pre-anesthetic bloodwork? *

Yes
No

Will bloodwork be completed at your hospital? [Minimum requirement - Chem 15, CBC, Lytes. Needs to be completed within 2 months for young pets (under 7 dogs 10 for cats) or 1 month for senior pets (over 7 dogs or 10 for cats)]. *

Yes
No
Unsure

We recommend a 2 week post-op for pets with extractions? Would you like us to complete the post-op? *

Yes
No

We require pre-visit pharmaceuticals to be given 2 hours prior to their surgery. Below is the dosing we need for both canine and feline patients. Would you like us to fill these for the patient? Canine Patients - 30 mg/kg gabapentin Feline Patients - 100mg gabapentin 1 dose of Cerenia *

Yes
No

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