Clinic Hours:
Monday – Friday, 7AM – 5:30PM
|
Phone:
719-536-9949
|
Email:
info@wellpets.com
Contact Us
About Us
Our Practice
Our Team
Partners & Events
Services
Pet Dental Cleanings
Specialty Anesthesia
Dental Imaging
Endodontics
Orthodontics
Oral Surgery
Oral Tumors
Oral Medicine
Periodontics
Restorations
Discolored Teeth
Cone Beam CT
Pet Parents
What is a Board Certified Veterinary Dentist
®
?
New Patient Forms & Payment Options
Pet Parent Resources
Pet Dental FAQ’s
Home Dental Care for Cats
Home Dental Care for Dogs
Anesthesia-Free Cleaning for Pets
Pet Anesthesia
Pet Dental Pain
New Pet Dental Care
Veterinary Colleagues
New Referral
DVM, DAVDC Job Opening
Dental Courses
Vet Dental Courses
Evening CE
Blog
Contact Us
Castle Rock
Colorado Springs
Pueblo
Monument
About Us
Our Practice
Our Team
Partners & Events
Services
Pet Dental Cleanings
Specialty Anesthesia
Dental Imaging
Endodontics
Orthodontics
Oral Surgery
Oral Tumors
Oral Medicine
Periodontics
Restorations
Discolored Teeth
Cone Beam CT
Pet Parents
What is a Board Certified Veterinary Dentist
®
?
New Patient Forms & Payment Options
Pet Parent Resources
Pet Dental FAQ’s
Home Dental Care for Cats
Home Dental Care for Dogs
Anesthesia-Free Cleaning for Pets
Pet Anesthesia
Pet Dental Pain
New Pet Dental Care
Veterinary Colleagues
New Referral
DVM, DAVDC Job Opening
Dental Courses
Vet Dental Courses
Evening CE
Blog
Contact Us
Castle Rock
Colorado Springs
Pueblo
Monument
New Patient
New Patient Form
Client Info
Primary Phone
Home
Mobile
Fax
Work
Allow Text
Secondary Phone
Home
Mobile
Fax
Work
Allow Text
Additional Phone
Home
Mobile
Fax
Work
Allow Text
Patient Info
Species:
Canine
Feline
Sex
Male
Male Neutered
Female
Female Spayed
Approximate date of birth
Patient Medical Info
Please list the family veterinarians to whom you would like a summary letters forwarded. Include Hospital and Veterinarian's Name
Please indicate the veterinarians we need to obtain records from. Include Hospital and Veterinarian's Name.
Reason for your visit
List of Major Medical Problems
List of current medications/doses/frequencty
History of dental problems/treatment
Allergies to food or medication
Vaccinations of to date
Yes
No
Date of last blood work
Diet
Check any of the oral symptoms noted below
bad breath
loose teeth
growths on the gum
discolored teeth
failure to lose baby teeth
reluctance to chew hard items
fractured/broken teeth
red or bleeding gums
other
Please check the toys/treats provided
kongs
bones
raw hides
frisbees
rope toys
dog biscuits
ice cubes
tennis balls
greenies
plush/squeaky
nylon toys
antlers
other
Please indicate your pet's current dental home care (if any) and the frequency it is provided (examples - brushing, rinse, dental diet, dental chews, water additive.)
TREATMENT AUTHORIZATION and INFORMATION/PHOTO RELEASE
I hereby authorize the veterinary team of Animal Dental Care & Oral Surgery (“ADCOS”) to examine, prescribe for, and treat my pet.
I understand that I will receive a summary of the care provided in order to ensure that my pet's care can be continued without interruption.
I also understand that the identification of a referring veterinarian by me to be my authorization for ADCOS to obtain medical records, as well as release records and information to that veterinarian. Case information, medical images, photos and/or videos of my pet(s) may be used in teaching forums, continuing education, hospital web site, veterinary literature, and the like. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained.
FINANCIAL POLICY
Payment is due as services are rendered. The balance will be due upon discharge from the hospital. You may pay by cash, Care Credit, or accepted credit cards. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance.
I understand that I (the owner or agent) am financially responsible for all charges relating to this patient.
I have read and agree to the treatment authorization.
I have also read and accept the financial obligations.
Signature
Today's Date
How did you find us
How did you find us?*
Vet Referral
Family or Friend
Online Search
Social Media
Website
Other
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