"*" indicates required fields

Owners Name*
New or Returning Client?*
Other Interested Party
Primary Care Veterinary Hospital(s)*
Specialty Care Veterinary Hospital(s)*
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Appointment Type?*
Do we have permission to share your pet’s medical records with your primary care veterinarian?*
Can we use the digital images of your pet’s mouth for educational and/or social media purposes?*
Pet Information*
Pet's Name
Canine / Feline
Spayed / Neutered
Current on Rabies vaccine?
Click the "+" icon to add a second pet
Initial, indicating approval

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.

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