Client (Owner) Name* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell Phone*Email* Alternate Contact First Last PhoneOccupation/Place of Business How did you hear about us?* Pet’s InformationPatient (Pet) Name* Breed* Color* Date of Birth/Age* Sex* Spayed/Neutered* Yes No Veterinary Hospital* Dr.’s Name Major medical/surgical history* Current medications* Allergies or drug reactions* Are vaccinations up to date?* Yes No Is your pet a fear biter?* Yes No Not sure Has your pet had professional dental care?* Yes No When & Where?* Do you practice home dental care?* Yes No If yes, what type and how often? I have read, understand and agree to the following: Payment is expected at the time services are rendered. We accept cash, Visa, MasterCard, American Express, Discover, Scratchpay and Care Credit. Animal Dental Clinic does not accept personal checks. In the event of a payment issue, you (the client) will be responsible for any/all legal fees incurred in the collection of the payment. A written treatment plan/estimate will be provided at any time, upon my request. A small amount of fur may need to be clipped for monitoring, IV catheter placement, etc. If I need to reschedule my appointment, I will give 48 hours’ notice. If I cancel with less than 48 hours’ notice or miss the appointment, a fee may be assessed. Photos may be taken of my pet's procedure for educational purposes and/or for use in online marketing. Pets should be picked up within 30 minutes of their release time. Otherwise, hospital charges may apply. Signature*CAPTCHA