"*" indicates required fields Client (Owner) Name* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* Medications given within the last 48 hours* 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: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.* InitialA written treatment plan/estimate will be provided at any time, upon my request.* InitialA small amount of fur may need to be clipped for monitoring, IV catheter placement, etc.* InitialIf 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.* InitialPhotos may be taken of my pet's procedure for educational purposes and/or for use in online marketing.* InitialPets should be picked up within 30 minutes of their release time. Otherwise, hospital charges may apply.* InitialSignature*CAPTCHA
