"*" indicates required fields Owners Name* First Last New or Returning Client?* New Client Returning Client Other Interested Party First Last 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 Email* Primary Phone Number*Secondary Phone Number/Home NumberPrimary Care Veterinary Hospital(s)* Add RemoveSpecialty Care Veterinary Hospital(s)* Add RemoveWhat date is your pet's appointment?* MM slash DD slash YYYY Reason for VisitAppointment Type?* Consultation Procedure Consultation and Procedure on the same day 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 NameBreedColorBirthday/AgeCanine / FelineSexSpayed / NeuteredCurrent on Rabies vaccine? Add RemoveClick the "+" icon to add a second petWe 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 approvalI understand that payment is due at the time services are rendered. The Veterinarian always performs a thorough gross examination during consultation. There is a fee for this service whether a procedure is performed or not performed/declined. 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* MM slash DD slash YYYY
