"*" 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 RemoveDoes your pet have insurance?YesNoAre you planning on filing an insurance claim for your pet’s medical procedure?YesNoSpecialty 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 petAppointment 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.Consent* I have read and understand Atlanta Veterinary Dental Service cancellation policy 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* MM slash DD slash YYYY
