New Patient Form: Dentistry

If your pet has an upcoming Dentistry appointment with Dr. Barden Greenfield, please complete the specialty form using one of the options below. 

Dental & Oral History

Please answer the following questions to the best of your knowledge. 

Patient Name *

What is the present oral complaint that is affecting your pet? *

Approximately how long has this problem been going on? *

Was this problem either seen or treated by a veterinarian? *

Yes No

If yes, when was the last oral/dental treatment performed?

If an oral procedure was performed by your family vet, did they perform diagnostic dental x-rays on that day?

Do you routinely do any of the following (Choose all that apply)

Brush pet's teeth

Give pet daily chews

Rinse pet's mouth with approved dental rinses

Has your pet had any past or is experiencing present illnesses? *

Yes

No

If yes, please list.

Please list any medications your pet is currently taking (i.e. Heartworm prevention, Anti-inflammatory medications (Rimadyl, Previcox, Metacam) , Antibiotics (Clavamox, Antirobe/Clindamycin, thyroid medication, insulin, others)

Has current blood work (wellness scan or pre-anesthetic blood panel) been performed by your family veterinarian within the last three months? *

Yes No

Who is your family veterinarian? *

Name of Family Veterinary Practice *

Post-Procedure Communication

Dr. Greenfield or Tammy/Rayanna (his technician) would like to communicate with you the next day or so following the procedure. This helps us better follow your pet’s progress to normal dental health.

Pet Owner Name *

Email Address

Phone *

By submitting this form, I agree to the above.