Date of Birth
Do you have Insurance?YesNo
Spayed / Neutered?
Approximate date of birth
Please list the family veterinarians to whom you would like a summary letter forwarded, include Hospital and Veterinarian’s name
Please indicate the veterinarians we need to obtain records from; include Hospital and Veterinarian’s name
Date of last blood work
Location of last blood work
Never Had Lab Work/Not Sure
Reason for your visit
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
History of dental problems; include problem, treatment, treatment location, and if dental x-rays were performed
Please indicate your pet's current dental home care (if any) and the frequency it is provided
(examples - brushing, rinse, dental diet, dental chews, water additive)
Please check the toys/treats provided
kongsbonesraw hidesfrisbeesrope toysdog biscuitsice cubestennis ballsgreeniesplush/squeakynylon toysantlersother
List of Major Medical Problems
List of current medications/doses/frequency
Allergies to food or medication
I hereby authorize the veterinary team of Animal Dental Services Knoxville 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 Animal Dental Services Knoxville 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.
Payment is due as services are rendered. The balance will be due upon discharge from the hospital. You may pay by cash, Care Credit, or accepted credit cards.
In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance.
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.
How did you find us
How did you find us?*Vet ReferralFamily or FriendOnline SearchSocial MediaWebsiteOther