"*" indicates required fields

Owners Name*
New or Returning Client?*
Other Interested Party
Address*
MM slash DD slash YYYY
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
Breed
Color
Birthday/Age
Canine / Feline
Sex
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. 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.

MM slash DD slash YYYY