Consultation Request

Step 1 of 4

Thank you for requesting consultation at Animal Dental Clinic. In order to schedule your pet’s consultation, we will collect some basic information about you and your pet.

Client information (contact information to be used only to communicate with you about your pet’s care)

First Name*

Last Name*

Phone Number*

Please indicate whether this is a landline or mobile number*

Landline

Mobile

Street Address*

City*

State*

Zip*

Does anyone else take your pet to veterinary care appointments?*

(medical records at other hospitals may be listed under their name instead of yours; please include their contact information if you would like us to be able to reach them about your pet’s care)

Secondary First Name*

Secondary Last Name*

Secondary Phone Number*

Secondary Email

Do you have a preference for meeting with Dr. Nicodin Farcas or Dr. GG Comet Riggs?(Required)

Do you have a preference for meeting with Dr. Nicodin Farcas or Dr. GG Comet Riggs?*

Patient general information (this allows us to ensure that we are able to provide the best care for your pet, have all of the relevant information about your pet at the time of consultation, and can provide a complete summary to your pet’s other veterinary care providers)

Pet's Name*

Do you prefer to enter your pet’s exact birthdate, or his/her approximate age?*

What is your pet’s birthdate?*

Approximate Age Value*

Approximate Age Unit*

Pet's Sex*

Has your pet been spayed/neutered?*

Pet’s species*

Pet’s breed*

Pet's Weight*

(estimate if unknown)

Pet's Weight Unit*

Pet’s primary care veterinary practice*

(if your pet has not seen a veterinarian, please enter "none")

Pet's primary care Doctor Name

Does your pet receive care at any other veterinary practices?*

(Please list all: specialty practices, emergency practices, second or previous primary care practice, alternative therapy, vaccination clinic, etc.)

Other Practice Information

Other Practice(s)

Other Doctor(s)

Do you have a pet insurance policy in place for your pet?*

(this helps us to assist in the event of a claim appeal; it does not affect the care recommendations you will receive from us) Note: Care Plans purchased through Banfield and VCA hospitals are memberships that are not transferrable outside of the organization from which they were purchased.

Name of provider/insurance company*

Are you the policy holder?*

Policy holder’s first name*

Policy holder’s last name*

Policy holder’s email address

How does your pet feel about coming to veterinary visits?*

Happy to meet new people

A little nervous but fine if you go slow

Requires cautious handling

Dangerous

No judgement here; this helps us to start your pet’s visit off right from the start. (Please check all that apply/the closest description; we understand that there are a lot of gray areas)

Patient health information (since systemic health affects oral health, and because many of our patients require treatment under anesthesia, it’s important that we’re able to assess the general health of our patients, in addition to their dental/oral health)

Does your pet appear to be generally healthy at home?*

What do you notice about your pet that doesn’t seem right?*

Does your pet have a known history of drug allergy or previous adverse drug response?*

What is the medication?*

What is the reaction/response?*

Does your pet have a heart murmur or other known heart condition?*

Do you know what heart condition your pet has been diagnosed with?*

What is your pet’s diagnosis/what is the name of the condition?*

Does your pet have any symptoms of his/her heart condition?*

Please describe your pet's symptoms*

Has your pet been evaluated by a veterinary cardiology specialist?*

Approximate date*

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

What veterinary practice?*

Does your pet have chronic kidney disease?*

Does your pet have any symptoms of his/her kidney disease?*

What symptoms does your pet show that are related to chronic kidney disease?*

Has your pet been evaluated by a veterinary internal medicine specialist?*

Approximate date (or date last evaluated)*

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

What veterinary practice?*

Does your pet have any other known medical conditions (such as seizures, hyper- or hypothyroidism, liver disease, for example)?*

Condition 1: Name/describe diagnosis/condition/symptoms

Has this resolved?

What veterinary practice has last evaluated and/or treated your pet for this condition?*

When was this last evaluated/treated?

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

Does your pet still receive treatment (or take medication) for this condition?*

Please describe treatment or medication

Has your pet been examined by a veterinarian in the past year for general wellness or to follow up on ongoing problems?*

Practice name*

Approximate date*

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

Has a veterinarian performed routine laboratory evaluation in the past year?*

(complete blood count, serum chemistry, with or without urinalysis: these are commonly done either as general wellness screening or pre-anesthetic screening testing, or to evaluate status of an ongoing medical concern)

Practice name*

Approximate date*

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

Does your pet receive any medications (regularly or occasionally; besides flea/tick and heartworm preventatives)?*

Medication 1: drug name*

Drug strength (usually this is mg for tablets/capsules or mg/mL for liquid medications)*

Number or fraction of tablets or mL given per dose (ex: 2 tablets, or ½ mL)*

Frequency of administration (ex: twice daily, or 3 times per week)*

Administration Frequency Unit*

Does your pet receive any dietary or nutritional supplements?*

Please list each supplement

Does your pet receive flea preventative medication regularly?*

Does your pet receive heartworm preventative medication regularly?*

Is your pet currently vaccinated for rabies?*

Was this performed by your primary care veterinary practice?*

Veterinary practice that performed the vaccination*

How do you describe your pet’s appetite normally?*

Has your pet had any appetite changes recently?*

Has your pet’s appetite increased or decreased recently, compared to normal for him/her?*

Since when have you noted this change (approximate date)?*

Numeric input please, ex: 1-1-2022, 1/1/2022, 1/2022, 2021

Is there anything you would like to describe about a change in your pet’s appetite?

Appetite Change Description

What does your pet normally eat (main diet; select all that apply)?*

Commercial dry food

Commercial canned (or fresh or frozen or dehydrated) food

Home-prepared (human) food

Does your pet eat a raw meat-based diet?*

If dispensing oral medications, do you think it will be easier to give your pet tablets or liquid medications? Please note that not all medications allow an option.

Is there anything else that you think we should know about your pet?*

What else should we know?

By submitting this form, I certify that I will be respectful in all interactions with Animal Dental Clinic staff

By submitting this form, I agree to accept financial responsibility for all evaluations and treatments for my pet, about which I have been advised and have agreed to having performed for him/her

By submitting this form, I authorize Animal Dental Clinic to request and receive my pet’s medical records from other veterinary care providers, and to provide a record of evaluation and/or care received at Animal Dental Clinic to relevant veterinary practices and the insurance provider listed above (if applicable)

If informed that my pet’s rabies vaccination is not current, I will plan to update in no later than 2 weeks prior to my consultation at Animal Dental Clinic

Client information (contact information to be used only to communicate with you about your pet’s care)

Patient general information (this allows us to ensure that we are able to provide the best care for your pet, have all of the relevant information about your pet at the time of consultation, and can provide a complete summary to your pet’s other veterinary care providers)

Patient dental health information (we want to know specifically what brings you to us)

Patient health information (since systemic health affects oral health, and because many of our patients require treatment under anesthesia, it’s important that we’re able to assess the general health of our patients, in addition to their dental/oral health)