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Relationship to Owner
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OK to text phone number(s)? (required)
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Employer
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Spouse's Employer
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E-Mail Address :
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Spouse's E-Mail Address :
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Name of regular veterinarian or veterinary hospital (required)
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How did you hear about us? (required)
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Pet's Name (required)
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Species (required)
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Breed (required)
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Description (Colors and Markings)
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Date of Birth (required)
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Sex (required)
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Brand of Pet Insurance
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Please select yes below to show that you've read and understand our below-noted hospital policies: |
Payment is due in full at the time services are rendered. We accept all major credit cards, CareCredit, and Scratchpay. We do not accept checks or cash. We will always prepare a written estimate prior to any treatment. Please ask a staff member or doctor. (required)
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I understand that Animal Dental Specialists operates on a curbside basis and only my pet will be allowed inside the building. More information can be found here: https://www.adsuny.com/closed-lobby (required)
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I authorize Animal Dental Specialists and its agents to take photos of my pet and copyright, use, and publish the same in print and/or electronically. |
I agree that Animal Dental Specialists may use such photographs of my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. |
(required)
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Does your pet experience fear, anxiety, or stress during car rides or veterinary visits? Has he or she ever taken any medication because of this? (required)
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What prior health or medical problems has your pet experienced? (required)
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Is your pet on any medications, nutraceuticals, or herbal supplements? If so, which ones? (required)
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Describe your pet’s previous experience(s) with anesthesia, sedation, and pain medications. (required)
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What other concerns do you have? (required)
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