Canine Dental Chart Form

Canine Dental Chart Form
Use this form to record a dog’s dental exam findings, chart each tooth, document treatment, and note follow-up recommendations.
Patient & Owner Information
Dog Name
Breed
Date of Birth
MonthDayYear
Date
Sex / Reproductive Status
Weight (kg)
Owner Name
First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Visit & Dental History
Visit Date
MonthDayYear
Date
Reason for Visit
Prior Dental Cleanings or Procedures
Current Concerns
Other
Known Allergies or Medications
Oral Health Screening
General Oral Condition

1
2
3
4
5
6
7
8
9
10
1 is Poor, 10 is Excellent
Gingival Health

1
2
3
4
5
6
7
8
9
10
1 is Poor, 10 is Excellent
Plaque/Tartar Severity
Other
Calculus Present
Halitosis Present
Gingival Inflammation
Oral Pain Sensitivity
Observations: Tongue, Palate, Lips, and Mucosa
Treatment Performed
Prophylaxis/Cleaning Performed
Scaling Method
Polishing Performed
Fluoride or Other Topical Treatment Applied
Extractions Performed
Radiographs Taken
Anesthesia Used
Treatment Notes
Recommendations & Follow-Up
Recommended home care instructions
Medications prescribed or advised
Referral needed
Follow-up date
MonthDayYear
Date
Urgency of recheck
Additional veterinarian comments
Should be Empty:

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