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

Dental Clinic Interest Form

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?*
- Grade 1 - Minor - Soft plaque has built up on the surface of the teeth. A small amount of tartar is also present. Tartar was formed when mineral deposits from saliva precipitated in plaque. Bacteria have grown, multiplied and invaded the gum tissues around the tooth causing early gingivitis, and red, inflamed gums.
- Grade 2 - Moderate - Moderate tartar buildup is present. It has acted as a wedge, pushing the gums away from the teeth, causing food, bacteria, and debris to accumulate there. The gums are red, swollen, and bleed when touched.
- Grade 3 - Major - Plaque and tartar formation is heavy. Pockets of bacteria and debris have accumulated to form further pockets of infection along the teeth. The infection has destroyed tissues around the teeth that hold them in place, and some have become loose. The gums appear bright red and bleed freely.
- Grade 4 - Severe - Severe tartar formation and gum disease is present. Toxic debris and inflammation have caused extensive tissue death. Roots are infected, abscessed, and rotten. The thin wall of bone surrounding teeth has deteriorated, and many teeth are loose. Pain may also be severe at this stage.
*Please be honest and do your best to assess the grade, as it will help our veterinarian prepare for surgery!*

Dental Clinic Interest Form

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