Online Dentistry and Oral Surgery Registration Form Dentistry and Oral Surgery Registration Form Please enable JavaScript in your browser to complete this form.OWNER INFORMATIONOwner's Name: *FirstMiddleLastCo-owner/Spouse's Name:FirstMiddleLastHome Phone:Work Phone:Cell Phone:Other Phone (Co-Owner/Spouse Work or Cell):WorkCellOtherBest Phone Number: *Best Time to Call:Email Address: *Fax Number:Mailing Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCheck if Street Address is same as Mailing AddressCheck box if Same as AboveStreet Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of Employer:Occupation:PATIENT INFORMATIONPet's Call Name: *Birthdate: (if unknown, give estimated age) *Breed: *Species: *CanineFelineOtherSpecies (if Other):Color:Sex:Male, IntactMale, NeuteredFemale, IntactFemale, SpayedREFERRING VETERINARIANName: *FirstLastHospital Name:City:State:Phone:PATIEMT HISTORYCURRENT MEDICAL HISTORYPlease describe your pet's current problem (symptoms) in your own words: *Current Medications (Including flea products, heartworm prevention, vitamins, supplements & herbal remedies): *Does your pet have issues:eatingdrinkingvomitingurinatingdefecatinglethargyweight-lossDescribe:Has your pet experienced any collapse episodes? NoYesIf yes, how often do they occur? How long did the event last?Did your pet urinate or defecate? Was your pet rigid or relaxed?Has your pet had any lab work or radio-graphs taken in the last 6 months?NoYesIf yes, explain:Do you have any specific concerns about your pet's condition?PAST MEDICAL HISTORYPlease check all that apply and describe:SeizureBlood TransfusionExposure to Toxic SubstancesAllergies to drugsOtherDescribe:Previous medical problems/surgeries:Is your pet aggressive to people or other pets?NoYesIf yes, describe:Is your pet up to date on vaccines?NoYesIf no, explain:Lives Indoors%Lives Outdoors%Other Pets in Household:When & where has your pet ever traveled outside Florida:At what age was your pet when you acquired him/her?What type of toys and chews is your dog given?Any history of separation anxiety?YesNoIs your dog a working dog?YesNoWhat type of work does your dog do (ie. apprehension, drug detection, retrieving, etc.)?What food does your pet eat?When eating, does your pet:Chew the foodSwallow whole without chewingDoes your pet drop food from his/her mouth when eating?YesNoAny incidents of vomiting, particularly in the morning or during the night?YesNoIf yes, please describe:Have dental x-rays been taken?YesNoIf yes, whom may we contact for copies?Method(s) of Payment:CashCheckVisaMastercardDiscoverCare CreditI am financially responsible for all professional fees related to the above-mentioned pet by the Institute of Veterinary Specialists. I understand that payment is due at the time of service. By signing this form, I attest that I have read and will comply with these terms.CommentSubmit
