Signature

Signing here acknowledges you have read and understood the document above.

Name *

First

Last

Email *

Owner Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Species *

Dog
Cat

Breed *

Sex *

Male
Male (Neutered)
Female
Female (Spayed)

Age/Date of Birth *

Date of last rabies vaccination *

Current weight in lbs. *

If your pet is taking any medications, please list below:

Items accompanying your pet's visit with Dr. DeForge (email reports to DonDeForge100@gmail.com and doctordeforge@yahoo.com) *

If other, please specify *

Last dental treatment (please include doctor, hospital, and date of treatment) *

Do you have dental X-rays from your last oral care visit? *

Yes
No

Primary oral problem (please include a detailed description of the problem, its location, duration, and progression, as well as treatment to date and their effect) *

Is your pet currently taking any medication? *

Yes
No

General Veterinarian's Name

First

Last

Hospital Name

Phone

Fax

Hospital Email

Do you wish your general veterinarian to be contacted and sent full reports from Dr. DeForge after he completes treatment?

Yes
No

What type of appointment would you like your recheck to be? *

Onsite
Virtual video telemedicine conference
With Dr. DeForge

How did you hear about us? *

Website
Personal Reference
Google Search
Other

If Other, please explain: *

Online Forms

Milford, CT

Advanced Oral Care Admission Form

Online Forms

Advanced Oral Care Admission

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Location

Contact Information

Hours