New Client Form Posted on September 23, 2020September 23, 2020 by Cheshire Marked Fields Are Required [*] "*" indicates required fields Please Schedule Your Appointment Before You Complete This FormDate MM slash DD slash YYYY Please tell us about your concerns today. Check all that apply. Anesthesia Concerns Tooth Resorption Oral Pain Oral Mass Fractured tooth Fractured Jaw Stomatitis Periodontal Disease Other Please explain:*Owner InformationName* First Last Email* Cell/Pager* Home Phone Business Phone 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 Workplace & Occupation* Spouse / Partner First Last Spouse / Partner Workplace & Occupation Spouse / Partner Phone Patient InformationPatient's Name* Species* Dog Cat Gender* Male Female Spay / Neutered?* Yes No Breed* Color* D.O.B* Age* Any known allergies or drug reactions:*Regular Veterinarian:* Clinic name:* How did you hear about us?* Hospital Policy: Animal Dental Clinic abides by a veterinary referral Code of Ethics. If you’re pet has been referred by your veterinarian for treatment with the Animal Dental Clinic and requires medical attention unrelated to an oral condition, please contact your primary care veterinarian for further assistance.* I agree and understand Estimate: An itemized estimate will be provided for the recommended diagnostic and treatment procedures.* I agree and understand Payment: Payment is due at the time of service. We accept Visa, Mastercard, Discover Care Credit, H3 Wellness and debit cards, in addition to checks and cash.* I agree and understand Credit: The Animal Dental Clinic cannot extend credit. If you think that you might require payment options, please ask the receptionist for information about lending companies we work with after your consultation appointment, prior to scheduling your procedure.* I agree and understand We often use patient pictures for our website or Facebook. We may also use medical cases for veterinary journals or publications. Your initials below give ADC authorization to release portions of your pet's medical history and record, including personal recollections, radiographs, photographs, testimonials, videotape images or other images for use in the print media, on a brochure, the OVH website, social media outlets, and veterinary publications.* I approve I decline Signature Reset signature Signature locked. Reset to sign again You must click on the Submit button below after you verify the Captcha code.When you submit this form, there will be a link on the next page to fill out our Pre-Consultation Questionnaire if you have not done so already. They must both be submitted to us prior to your initial scheduled appointment. Thank YouCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.