Dentistry & Oral Surgery Questionnaire

Owner Full Name *

Owner Phone Number *

Spouse (or second contact) Full Name

Owner (secondary) Phone Number

Referring Veterinarian Name *

Referring Veterinary Practice *

Owner Email Address *

Do you have medical insurance for your pet? *

Yes
No

Pet Name *

Date of Birth *

Breed *

Gender *

Is your dog a working-dog? *

Yes
No

Do you consent to your pet being featured in educational or promotional materials (e.g., websites, social media, or presentations)? This may include photos, diagnostic images, medical information, and your pet's first name. *

Yes
No

How long have you owned your pet? *

Is your pet up to date on vaccinations? *

Yes
No

What kind of food is your pet eating? *

Does your pet prefer wet or dry food? *

Wet
Dry

Are there any kids at home? *

Yes
No

Are there any other pets at home? *

Yes
No

Is your pet on any medication? *

Yes
No

Any travel history outside of Alberta? *

Yes
No

Has your pet had any previous dentistry/oral surgery procedures? *

Yes
No

Do you offer any oral treats, chews, toys, oral rinses? *

Yes
No

Do you brush your pet's teeth? *

Yes
No

How interested are you in learning more about tooth brushing? *

Very
Somewhat
Not interested

Please be as descriptive as possible with your answers if your pet has any of the following concerns.

Does your pet have any concerns with constipation? *

Does your pet have any concerns with breathing issues? *

Does your pet have any concerns with exercise intolerance and/or weakness? *

Dentistry & Oral Surgery Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

MEDICAL HISTORY

MEDICAL QUESTIONS

Dentistry & Oral Surgery Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

MEDICAL HISTORY

MEDICAL QUESTIONS

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