Owners Name*

First Last

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*

Primary Care Veterinarian’s Name*

What date is your pet's appointment?*

Appointment Type?

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 Name	Breed	Color	Birthday/Age

Species*

Canine
Feline

Sex*

Is your pet spayed/neutered?*

Is your pet current on his/her Rabies vaccine?*

Yes
No

We 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 approval

I 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