New Patient Form in Vienna, VA | Animal Dental Clinic

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

Name

Breed

Color

Date of Birth/Age

Sex

Spayed/Neutered

Veterinary Hospital

Dr.’s Name

Major medical/surgical history

Current medications

Allergies or drug reactions

Are vaccinations up to date?

Is your pet a fear biter?

Has your pet had professional dental care?

When?

Do you practice home dental care?

If yes, what type and how often?

I have read, understand, and agree to the following:

Payment is expected as services are rendered. Discover, Visa, MasterCard, American Express, Care Credit, and Cash are the accepted forms of payment.
Animal Dental Clinic will no longer be accepting personal checks.
A written treatment plan will be provided at any time, upon my request.
A small amount of fur may need to be clipped for monitoring/IV catheter placement.
If I need to reschedule my appointment I will give 48 hours notice. If I cancel with less that 48 hours notice or miss an appointment, a fee will be assessed.
Photos may be taken of my pet’s procedure for educational purposes.

Signature*