New Patient Form

Client (Owner) Name*

First Last

Date*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone*

Email*

Alternate Contact

First Last

Phone

Occupation/Place of Business

How did you hear about us?*

Pet’s Information

Patient (Pet) Name*

Breed*

Color*

Date of Birth/Age*

Sex*

Spayed/Neutered*

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?*

Is your pet a fear biter?*

Has your pet had professional dental care?*

When & Where?*

Do you practice home dental care?*

If yes, what type and how often?

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*

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