Questionnaire-Referral

• First Name:

• Last Name:

• Spouse/Alternate owner:

• Address:

• City/Town:

• Postal Code:

• E-mail:

• Home Phone:

• Work:

• Cell/Other:

• Preferred method of contact:#Home#CellE-mailTextMail

• Referring Veterinarian/Clinic:

• Pet's Name:

• Status:MaleFemale

• SpayedNeuteredunaltered

• Species:

• Breed:

• Birth Date or Approx. Age:

• Colour/Marking:

• Does your pet have problem withother dogscatsmenchildrenchewingbiting/aggressionhousetrainingOther

• Other - Please explain:

• Has your pet ever growled or bitten (including in-hospital)?YesNo

• General Health:

• I would describe my pet as:NormalHyperactiveLethargic

• Water intake:NormalDecreasedIncreased

• Appetite:NormalDecreasedIncreased

• Urination:NormalDecreasedIncreased

• Stools:NormalWateryHard/Dry

• Coughing/Sneezing/Breathing Difficulty:YesNo

• If yes, Please explain:

• Is your pet currently on any medications?YesNo

• If yes, what medication(s)?

• Diet:

• Do you feed dry kibble or canned food?

• Do you currently soak kibble?YesNo

• What brand of food do you feed?

• Does your pet receive people food?

• What is your current method of dental hygiene?Toothpaste/Brushing TeethDental Chews/GreeniesWater AdditivePlaque OffMaxiguard WipesNothing

• If you brush your pet's teeth, How often?MonthlyWeeklyDailyNeverRarely

• Do you use any specialty dental products?MaxiguardChlorhexidine RinseToothpasteNothing

• Other:

• Does your pet have bad breath?YesNoDon't Know

• Do you have pet insurance?YesNo

• If yes, Who is your provider?

• I already have an appointment booked.I would like to be contacted to arrange an appointment.

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