Oral and Dental History – Finished

Patient Registration


Today Date:   

CLIENT INFORMATION

Name:   
Email:   
Address: 
 
Primary contact #:    | Secondary contact #:    | Work #:   

Spouse/Other Authorized Contact Name:  

How did you become aware of our practice?   
 

PATIENT INFORMATION

Pet’s Name:    | Breed:    | Color:   
Date of Birth:  | or Estimated Age: 
Sex:  | Spayed/Neutered?  | Vaccination history (including rabies) Up to date: 

Please list any medications/supplements your pet is taking (i.e. fish oil, etc...):  

Please list any illnesses/surgeries your pet has had:  

Approximately how long have you had your pet? | How did you acquire him/her?  

What is your pet’s normal diet?  

Do you provide any at-home oral care for your pet?  

Please describe the reason for your visit today.  

Are there any symptoms of oral pain at home?  

Does your pet have a known heart murmur or other cardiovascular problem?:  

Does your pet have any other health problems that we should be aware of?  

, I authorize AD&OS to take photographs and other documentation of my pet for educational and promotional purposes. All images, documents, videos, and other media will be altered to omit names and other identifying marks as to maintain confidentiality. I hereby grant consent for use of these documents without compensation and release AD&OS from any and all claims arising from the use of these documents.

I hereby acknowledge that AD&OS does not bill fees and that payment is expected at the time services are rendered. All major credit cards, care credit, and cash are accepted. Checks are not accepted.

VIRGINIA VETERINARY HOURS DISCLOSURE FORM

In accordance with state law, we request that you read our stated hours of operation and sign below.

§ 54.1-3806.1. Disclosure forms required.

Any animal medical care facility in the Commonwealth, excluding those facilities dealing with livestock, as defined in § 3.2-5900, which does not provide continuous medical care for all animals left in its charge shall, before taking charge of an animal, provide the client or agent thereof with a disclosure form which specifies the hours and days when continuous medical care is not available at the facility. Such form shall be separate and apart from any other form or information provided by the facility. Except in emergency situations when time or circumstances do not permit, such facilities may take charge of an animal only after the client or agent thereof has signed the disclosure form and returned it to the facility. Only one signed form per client shall be required, and the form shall be kept on file by the facility.
1991, c. 621; 1998, c. 158.

Animal Dentistry & Oral Surgery Hours:

Monday – Friday: 8 AM - 5 PM
Saturday & Sunday: Closed

Holidays:

We are closed for the duration of the follow holidays:
New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the following Friday, Christmas Day and the week between Christmas and New Year’s Day.

I have read this form and I am aware of the operating hours of Animal Dentistry & Oral Surgery.

Mary Buelow, DVM Diplomate,
American Veterinary Dental College
165 Fort Evans Rd. NE, #106 Leesburg, VA 20176
P: 571-209-1146 / F: 571-319-8169
www.animaldentalspecialist.com
info@animaldentalspecialist.com

 

Leave this empty:

Signature arrow sign here

Signed by Mary Buelow
Signed On: March 6, 2024


Signature Certificate
Document name: Patient Registration
lock iconUnique Document ID: bb89b9c66f213ac52318c4c30308738e8c18d399
Timestamp Audit
April 24, 2019 1:10 am EDTPatient Registration Uploaded by Mary Buelow - info@animaldentalspecialist.com IP 153.209.132.192
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https://animaldentalspecialist.com/
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