Animal Doctor Westside Your Other Family Doctor MOUTH ISSUES First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. What changes have you noticed? * How long have you noticed a change? * Does your pet experience/have (check all that apply): * Bad breath Masses in/around mouth, tongue, and/or lips Discoloration of gums, tongue, lips, or teeth Dropping food Coughing Sneezing Vomiting Diarrhea None of the above How is your pet's appetite? * What kind of food are you feeding? How much per day? * How is your pet's thirst and urination? * Have you tried anything at home? Do you brush or give dental treats? * Any history of allergies/chewing fur/excessive grooming? * When was his/ her last dental cleaning? * Is the patient on any medications? Include dosage and frequency. * Are you administering heartworm preventative? What type and how often? * Are you administering flea/ tick preventative? What type and how often? * Do you have any additional questions or concerns you would like to address with the Doctor today? * Submit If you are human, leave this field blank.