New Client Form

Please:n1. complete the new patient registration formn2. present the completed form to our receptionist when you arriven3. contact your primary care veterinarian to request your pet’s medical records

Owner's Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Emergency Phone*
Email*
Does anyone else have permission to make decisions on behalf of your pet?
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Primary Phone
Emergency Phone
Email
I understand that payment in full is due at the time of service. I agree to assume financial responsibility for all professional fees, and agree to pay AVDS when services are rendered. I understand that a fee of 1.5% will be charged on any unpaid balance. AVDS may also recover reasonable attorney’s fees and court costs incurred as a result of my failure to pay in accordance with this authorization.
I agree to the above statement*
- Yes
- No
Date*
Date Format: MM slash DD slash YYYY
Pet Name*
Date of Birth*
Dog or Cat?*
Breed*
Color
Male or Female? Intact or Neutered?*
Medications
Vaccination Status
FeLV/FIV Status
Heartworm Status
Primary Care Hospital: Name & Address*
Primary Veterinarian*
Referring Veterinarian (if different from primary)

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New Client Form

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