Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Pet's Name *

Species *

Dog
Cat

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

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

Please list all medications, including name, dosage, and frequency *

General Veterinarian's Name

First

Last

Hospital Name

Hospital Phone

Hospital 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? *

On-site
Virtual video telemedicine conference
With Dr. DeForge

How did you hear about us? *

Website
Personal reference
Google search
Other

Whom may we thank for the referral? *

If other, please specify *

Self-Referral Form

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