New Client Form – Animal Dental Clinic

Please Schedule Your Appointment Before You Complete This Form

Date

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 Information

Name*

First Last

Email*

Cell/Pager*

Home Phone

Business Phone

Address*

Street Address Address Line 2 City State ZIP Code

Workplace & Occupation*

Spouse / Partner

First Last

Spouse / Partner Workplace & Occupation

Spouse / Partner Phone

Patient Information

Patient'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:*

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. Please ask the receptionist for options after your 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

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