Owners Name*

First Last

New or Returning Client?*

New Client

Returning Client

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(s)*

Does your pet have insurance?

Are you planning on filing an insurance claim for your pet’s medical procedure?

Specialty Care Veterinary Hospital(s)*

What date is your pet's appointment?*

Reason for Visit

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

Can we use the digital images of your pet’s mouth for educational and/or social media purposes?*

Yes

Pet Information*

Pet's Name

Breed

Color

Birthday/Age

Canine / Feline

Sex

Spayed / Neutered

Current on Rabies vaccine?

Click the "+" icon to add a second pet

Appointment Cancellation

Due to the nature of our dental practice, we offer a limited number of appointments each day. When you book your appointment, you are holding a space on our calendar that is no longer available to our other patients. In order to be respectful of your fellow patients, please call us immediately if you know you will not be able to make your appointment.

If cancellation is necessary, we require that you call at least 72 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.

We have trained staff to hold your pet during examination or treatment.

I 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*

Client Information Form | Atlanta Veterinary Dental Services

Appointment Cancellation

Online Pharmacy

Location

Office Hours

Client Information Form | Atlanta Veterinary Dental Services

Appointment Cancellation

Online Pharmacy

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