New Patient Form Dentistry

Please list the family veterinarians to whom you would like a summary letters forwarded. Include Hospital and Veterinarian's Name

Please indicate the veterinarians we need to obtain records from. Include Hospital and Veterinarian's Name.

Diet

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

Please check the toys/treats provided
kongsbonesraw hidesfrisbeesrope toysdog biscuitsice cubestennis ballsgreeniesplush/squeakynylon toysantlersother

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.)

I hereby authorize the veterinary team of Apex Veterinary Specialists (“Apex”) 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 Apex 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.

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.