Animal Dental Specialists / New Client Form

Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-5640

www.adsuny.com

New Client Form

Owner's Name (required)

First Name (required)	Last Name (required)

Spouse/Co-Owner's Name

First Name	Last Name

Relationship to Owner

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Primary Phone (required)
Phone Type	Phone Number (required)

Alternate Phone
Phone Type	Phone Number

Work Phone
Phone Type	Phone Number

Spouse Phone
Phone Type	Phone Number

OK to text phone number(s)? (required)

yes
no

E-Mail Address :

Spouse's E-Mail Address :

Select any that apply:
Active Military/Veteran
Veterinarian (DVM/VMD)
Licensed Veterinary Technicinan (LVT)
none

Name of regular veterinarian or veterinary hospital (required)

How did you hear about us? (required)

Internet
Saw our sign/live nearby
Referred by my regular veterinarian
Referred by a friend
Saw Spot (our mascot out front)
Other

Pet's Name (required)

Species (required)

dog
cat

Breed (required)

Description (Colors and Markings)

Date of Birth (required) :

Sex (required)

male, intact
male, neutered
female, intact
female, spayed

Brand of Pet Insurance

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)

yes

I understand that I can come inside the building with my pet for appointments with Dr. Davis (consultations) but that all surgery admissions and technician appointments operate on a curbside basis, meaning only my pet will be allowed inside the building. (required)

yes

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)

accept
decline

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)

What prior health or medical problems has your pet experienced? (required)

Is your pet on any medications, nutraceuticals, or herbal supplements? If so, which ones? (required)

Describe your pet’s previous experience(s) with anesthesia, sedation, and pain medications. (required)

What other concerns do you have? (required)

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