Low-Cost Dental Clinic Interest Form - Licking County Humane Society

Your Name*
First Last
Your Email*
Your Phone Number*
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Pet's Name*
Your Pet's Age*

Senior pets (8+ years) will require a wellness bloodwork panel to be completed before the surgery begins.
Your Pet's Type*
- Dog
- Cat
Your Pet's Sex*
- Male
- Female
Your Pet's Breed*
Your Pet's Color*
Your Pet's Weight*
Provide the best estimate if unknown.
What is your pet's dental grade? Compare your dog's mouth with images shown on previous page - lchspets.org/dental-clinic*
- Grade 1 - Minor - Visible plaque but no to mild inflammation or redness of gums (gingivitus)
- Grade 2 - Moderate - Moderate tartar buildup is present. Calculus staring to form. Mild inflammation or redness of gums (gingivitus)
- Grade 3 - Major - Plaque and tartar formation is heavy. Significant buildup of calculus. Moderate inflammation or redness of gums (gingivitus)
- Grade 4 - Severe - Plaque and tartar formation is heavy. Severe buildup of calculus. Significant redness of gums (gingivitus). Gum recession and tooth root abscess present
*Please, be honest and do your best to assess the grade, as it will help our veterinarian prepare for surgery!*