Dental Questionnaire Please complete the form below prior to your appointment. If you have any questions please email us at info@metro-vet.com. "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Owner Name First Last Pet InformationPet Name*Breed*Weight*Please include units (lbs or kg).Date of Birth* MM slash DD slash YYYY Species / Type*Sex* Male Male (Neutered) Female Female (Spayed) Dental & Medical HistoryWhat oral signs is your pet experiencing at home, or what did your primary veterinarian refer you to see the dentist for?*Is your pet eating and drinking consistently?* Yes No If no, how long has your pet not been eating or drinking?*Is your pet lethargic, hiding, or showing signs of oral pain?* Yes No If yes, please explain*Does your pet have any of the following conditions?* Diabetes mellitus Heart disease or murmur Kidney disease Thyroid disease Cough or tracheal collapse Bleeding disorders Addison’s disease (hypoadrenocorticism) None of the above What medications or supplements is your pet currently taking?*NameDoseFrequency Add RemovePlease include name, dose, and dosing frequency (e.g., Rimadyl 100 mg twice daily).Has your pet had any prior complications with general anesthesia?* Yes No If yes, please explain the anesthesia complications*Date of last CBC/Chemistry* MM slash DD slash YYYY Full lab work is required within 60 days of the dental consultation or surgery.Primary veterinarian*Contact InformationEmail address* Primary contact number*Preferred method of contact* Phone call Email Text message Financial & Appointment AcknowledgementAcknowledgement* I understand the consultation fee, estimated surgical costs, fasting instructions, and that surgery is generally performed the same day as the consultation. Signature*Date* MM slash DD slash YYYY
