Oral & Dental History Step 1 of 2 50% Today's Date Date Format: MM slash DD slash YYYY Client InformationName* First Last Email* Spouse/Other Authorized Contact Name First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary contact #*Secondary contact #Work #How did you become aware of our practice?DVM ReferralInternetPersonal RecommendationName of DVM ReferralName of Personal Recommendation Patient InformationPatient Name* First BreedColorDate of Birth Date Format: MM slash DD slash YYYY or Estimated AgeIn order to assess your pet’s oral health, we would appreciate if you could provide us with some important information by answering the following questions: SexFemaleMaleSpayed/Neutered?YesNoVaccination history (including rabies) Up to date:YesNoPlease list any illnesses/surgeries your pet has had:Please list any medications/supplements your pet is taking: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?YesNoIf so, what and how often?Please describe the reason for your visit todayAre there any symptoms of oral pain at home?Does your pet have a known heart murmur or other cardiovascular problem?:YesNoDoes 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*YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.
