Name: Atlanta Veterinary Dental Services
Address: 900 Mansell Rd, Suite 19, Roswell, GA, 30076, US
Telephone: +1-770-552-8777
Price range: $

Owners Name*
First Last
Other Interested Party
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Primary Phone Number
Secondary Phone Number/Home Number
Primary Care Veterinary Hospital*
Primary Care Veterinarian’s Name*
What date is your pet's appointment?*
Date Format: MM slash DD slash YYYY
Appointment Type?
Do we have permission to share your pet’s medical records with your primary care veterinarian?*
- Yes
- No
Can we use the digital images of your pet’s mouth for educational and/or social media purposes?*
- Yes
- No
Pet Information
Pet's Name Breed Color Birthday/Age
Species*
- Canine
- Feline
Sex*
Is your pet spayed/neutered?*
Is your pet current on his/her Rabies vaccine?*
- Yes
- No
We have trained staff to hold your pet during examination or treatment. If you elect to restrain your own pet during examination/treatment, please understand we cannot be responsible for any injury incurred to you or your pet.
Initial, indicating approval
I understand that payment is due at the time services are rendered. Payment may be made in the form of cash, check, Care Credit, and all major credit cards. I am aware there will be a penalty, up to the maximum allowed by law, for a check returned for any reason. I am responsible for all reasonable debt, expense, service charges and fees, including financial, legal, and by collection services/agencies, necessary in the collection of unpaid debt to AVDS. I further authorize AVDS and its financial institutions and agents to retrieve these funds.

I have read, understood, and verify all information provided by me above.
Signature*
Date
Date Format: MM slash DD slash YYYY

Pet's Name	Breed	Color	Birthday/Age