Name* First Last Date* Date Format: 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 BusinessHow did you hear about us?*Pet’s InformationName*Breed*Color*Date of Birth/Age*Sex*Spayed/Neutered*YesNoVeterinary Hospital*Dr.’s NameMajor medical/surgical history*Current medications*Allergies or drug reactions*Are vaccinations up to date?*YesNoIs your pet a fear biter?*YesNoNot sureHas your pet had professional dental care?*YesNoWhen & Where?*Do you practice home dental care?*YesNoIf 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*CAPTCHA
