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Owner Name

Phone Number

Email

Pet's Name

Pet Breed & Age

Date of last dental:

Medical History & Behavioral Information

Check any past/current patient problems. Please mark all that apply.

Please provide details to any conditions marked above:

We take the utmost pride in caring for your pet during their dental cleaning. We appreciate you taking the time to note any medical and behavioral issues that may apply and providing as much detail as you are able.

Treatment Authorization

By completing this form, I authorize this hospital to provide the above-mentioned pet's dental cleaning.

Consent

I give permission to Shores Animal Clinic to sedate my pet for the non-anesthetic dental if necessary.
No, I do not give permission for sedation.