dental-ap

Regional Veterinary Dental Center

Free Dental Check-Up Application

We are welcoming new clients and new patients to our practice with a Free First Dental Check-up! Please complete and submit the application below. You will be contacted within two business day by our Pet Concierge. Our Pet Concierge will help you plan your pet’s First Dental Check-up, where you’ll meet our caring team of pet people. At your pet’s First Dental Check-up it is our pleasure to meet you and your pet, to have you as our guest visiting the Dental Center, and to have the opportunity to educate guests about the health benefits of dental care. Your pet’s First Dental Check-up will include a thorough history and a dental exam. The history and exam provides us with an understanding of the symptoms that worry you, your pet’s overall dental problems, and your pet’s overall health situation. Once we understand the full scope of your pet’s individual situation we will provide you with an estimate for the care that your pet needs. At the conclusion of your pet’s First Dental Check-up you may schedule an appointment for your pet’s dental care needs. At Regional Veterinary Dental Center our goal is to provide personal, convenient, affordable, and thorough dental care. Our entire team looks forward to meeting you and your pets!
What is your name?
First Name:		Last Name:

What is your pet’s name, breed, age?
Name:
Breed:
Age:

What is your pet’s gender?
Female Female (spayed) Male Male (neutered)

What type of pet do you have?
Family Pet Show Pet Working Dog

Please fill out the following contact information:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Email:

How were your referred to Regional Veterinary Dental Center?
Hospital, Doctor Friend Self referred
Referrer’s Name:

What kind of dental problem is your pet having? (be as specific as possible)


When was your pet last normal?


Please list all medications (including dosages), holistics, and supplements that your pet is taking.


Does your pet have any other ongoing illnesses or health issues?


Is your pet allergic to any medications or anesthetics?