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About
Dentistry Services
- Equine Dentistry
- Small Animal Dentistry
Clinic Visits
Contact Us
Shop

About
Dentistry Services
- Equine Dentistry
- Small Animal Dentistry
Clinic Visits
Contact Us
Shop

Small Animal Intake Form

Small Animal Intake Form

"*" indicates required fields

1Owner

2Patient

3Medical Information

4Medications & Safety

Owner's Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Preferred method of contact*

Patient's Information

Name*

First

Species*

Dog

Cat

Sex*

Male

Male – Neutered

Female

Female – Spayed

Breed*

Color*

Birthday/Approximate Age*

Medical Information

Referring Veterinarian

Primary Veterinarian

Approximate date of last rabies vaccine*

Month

Day

Year

Proof of rabies vaccine

Rabies tag number/rabies certificate

Upload rabies certificate

Accepted file types: pdf, jpg, jpeg, Max. file size: 5 MB.

Has your pet had blood work done in the past 30 days?*

Yes

No

When was the blood work done?*

Month

Day

Year

Medications & Safety

Please list all medications your pet is currently taking:

Do you have antibiotics or pain meds at home for your pet?*

Yes

No

What kind(s) and how much?*

Does your pet have any health alerts?*

For example, Hypo/Hyperthyroidism, Heart murmur, Kidney Disease, FIV/FELV+

Does your pet have any behavioral alerts or concerns?*

Are you able to muzzle your pet if needed?*

Yes

No

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Clinic Location

Midwest Veterinary Dental Services
W3143 County Road D
Elkhorn, WI 53121

(844) 956-6837

midwestvetdental@thrivepet.com

Request an appointment

We usually book out 4-6 weeks for appointments. If you would like to request an appointment, please fill out the form.

Apply for Care Credit

Affiliated Organization

© Midwest Veterinary Dental Services. Site by Why The Fuss? Technical Solutions

About
Dentistry Services
- Equine Dentistry
- Small Animal Dentistry
Clinic Visits
Contact Us
Shop

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