New Client Information Form Owners Name* First Last New or Returning Client?* New Client Returning Client Other Interested Party First Last 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 Email* Primary Phone NumberSecondary Phone Number/Home NumberPrimary Care Veterinary Hospital*Primary Care Veterinarian’s Name*What date is your pet's appointment?* MM slash DD slash YYYY Appointment 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 InformationPet's NameBreedColorBirthday/Age Click the "+" icon to add a second petPet Information (continued)Canine / FelineSexSpayed / NeuteredCurrent on Rabies vaccine? Click 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. 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
