Client and Patient Information:
Your Name:
Your Pet's Name:
Date of Dental:
You Pet's Dental Health Information:
The level of dental hygiene that owners are able or willing to provide their pets can affect which dental therapies may be useful. To help our doctors get a complete picture of your pet’s dental health needs, please answer the following questions.
I brush my pet’s teeth:
Daily
Weekly
Monthly
Almost Never or Never
Are there any other treatments or products you use that are designed to help your pet’s teeth?
If Yes, describe:
My pet eats:
Dry Food
Wet Food
Dry and Wet Food
Table Food
What brand/type of food does your pet eat?
What kinds of treats does your pet eat?
OraVet™:
After we perform a complete dental cleaning, polish the teeth & apply a fluoride treatment, we can apply OraVet™. OraVet™ is a barrier sealant that helps prevent plaque bacteria from attaching to teeth, basically prolonging the life of today’s dental. As an option, we can apply the barrier sealant today. For further protection, in 2 weeks you can apply a similar plaque prevention gel weekly.
Cost of barrier sealant today:
< 25 lb pet $24.95 21-50 lb pet $34.95 >50 lb pet $39.95
Yes, I would like to have OraVet™ applied today.
Yes, I would like the at-home kit. (The at home plaque prevention gel comes with 8 packets which lasts 8 weeks for larger pets and 16 weeks or more for smaller pets.) If no, we will call to remind you to start using the at home kit in 2 weeks.
No, I decline the OraVet™ application.
Dental X-Rays:
Just like in human dentistry, many dental conditions cannot be properly diagnosed or could go completely undetected without dental x-rays. We offer our patients the latest in digital dental x-rays. This provides our doctors with the best information in the shortest amount of time. Please choose the statement below regarding dental x-rays for your pet.
I would like full mouth dental x-rays to be taken to detect any dental disease that would not be detected otherwise. (Full mouth x-rays cost $69)
I decline full mouth dental x-rays, but I authorize x-rays if the doctor has detected a problem and needs additional information to determine the best treatment.
(Single site $45, multiple sites $69)
I would like a staff member to call me before authorizing any x-rays.
I decline dental x-rays under any circumstances.
As the owner or representative of the owner, I authorize the surgery/anesthetic procedures outlined in my estimate. I do hereby acknowledge that I understand that there are no guarantees either implied or expressed that the procedures authorized will be without complications from unexpected events beyond the veterinarians’ and hospital’s control.
Signature
Date
