New Patient New Patient Form Client Information Primary Phone HomeMobileFaxWork Allow Text Secondary Phone HomeMobileFaxWork Allow Text Additional Phone HomeMobileFaxWork Allow Text Patient Information Species: CanineFeline Select Patient Sex & Reproductive Status —Please choose an option—Intact MaleNeutered MaleIntact FemaleSpayed Female Approximate date of birth Patient Medical Information Please indicate any hospital or veterinarian (primary, specialty, referral, etc) we need to obtain medical history from in preparation for your appointment. Please list the family veterinarian to whom you would like complete medical records forwarded to after your visit. Include hospital and veterinarian's name. List of major medical problems: History of dental problems/treatment List of current medications and/or supplements - name/dose/frequency: List of allergies (medication, food, environmental): Diet Check any of the oral symptoms noted below: bad breathloose teethgrowths on the gumdiscolored teethfailure to lose baby teethreluctance to chew hard itemsfractured/broken teethred or bleeding gumsother Indicate your pet's current dental home care (if any) including brand name and frequency. Examples: teeth brushing, oral rinse, dental diet, dental chews, water additive Check the toys and treats provided: kongsbonesraw hidesfrisbeesrope toysdog biscuitsice cubestennis ballsgreeniesplush/squeakynylon toysantlersother TREATMENT AUTHORIZATION and INFORMATION/PHOTO RELEASE I hereby authorize the veterinary team of Veterinary Dental Specialists of Missouri to examine, prescribe for, and treat my pet.* I understand that I will receive a summary of the care provided in order to ensure that my pet's care can be continued without interruption.* I also understand that the identification of a referring veterinarian by me to be my authorization for Veterinary Dental Specialists of Missouri to obtain medical records, as well as release records and information to that veterinarian. Case information, medical images, photos and/or videos of my pet(s) may be used in teaching forums, continuing education, hospital web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained.* FINANCIAL POLICY Following an in-office consultation, a comprehensive estimate for recommended treatment will be provided and reviewed. Payment is due as services are rendered. We accept various payment options, including major credit cards and CareCredit. Feel free to contact our office if you have any questions about financing options. I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.* I have read and agree to the treatment authorization.* I have also read and accept the financial obligations.* Signature*Today's Date* How did you find us How did you find us?*Vet ReferralFamily or FriendOnline SearchSocial MediaWebsiteOther Please Specify
