Animal Dental Specialists of Upstate New York

6867 East Genesee Street
Fayetteville, NY 13066

(315)445-5640

www.adsuny.com

New Client Form Form

Owner's Name (required)
First Name (required)
Last Name (required)
Spouse/Co-Owner's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Primary Phone (required)
Phone TypePhone Number (required)
Alternate Phone
Phone TypePhone Number
Work Phone
Phone TypePhone Number
Spouse Phone
Phone TypePhone Number
OK to text phone number(s)? (required)

yes
no


Employer

Spouse's Employer

E-Mail Address :
Spouse's E-Mail Address :
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/no 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, Scratchpay, and cash. We do not accept checks. We will always prepare a written estimate prior to any treatment. Please ask a staff member or doctor. (required)

yes
no


I understand that my pet will be treated on a referral basis only, that I will not be accepted as a general client of this practice, and that my pets will not be accepted as general patients of this practice. (required)

yes
no


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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HOURS


Day Open Close
Monday *7:00am 6:00pm
Tuesday *7:00am 6:00pm
Wednesday *7:00am 6:00pm
Thursday *7:00am 6:00pm
Friday 7:00am 2:00pm
Saturday Closed Closed
Sunday Closed Closed

*Scheduled surgical procedure days.


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Contact

Phone:  315-445-5640

Email:  contact@adsuny.com


Fear Free Certified Professionals