Date *

Agency Name *

Select One *

Animal Control
Police Department
Rescue Organization

Handler/Foster (if applicable)

Phone Number

Medical Decisions:

Name *

Position *

Phone *

Email *

Financial Decisions:

Name *

Phone

Email *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Purchase Order Number (if applicable)

Referred By/Veterinary Hospital:

Name *

Phone

Additional Veterinary Hospital for Records:

Name

Phone

Species *

Cat
Dog

Patient Name *

Date of Birth *

Sex *

Male
Female

Neutered or spayed *

Yes
No

Breed *

Color *

Reason for Referral:

Please list any other health issues *

Is the animal currently receiving any medications? *

Yes
No

If yes, please list: *

Is the animal allergic to any medications? *

Yes
No

If yes, please list: *

Has the animal had any known complications during anesthesia? *

Your veterinarian has referred you to Lone Star Dentistry & Oral Surgery for Animals out of trust and concern that your pet be provided the opportunity to receive advanced veterinary dental care. By signing below, you hereby authorize Dr. Todd McCoy, Dr. Kristin Kocsis and/or their associates of the Lone Star Dentistry & Oral Surgery to examine and treat the described pets listed in your file. You agree to maintain your relationship with your primary veterinarian for health and wellness issues not related to dentistry. Permission to release medical history is also granted, unless otherwise stated or revoked. *

I have read and understand

You assume financial responsibility for the care of your pet(s) and understand payment is due in full at the time that services are performed. All major credit cards are accepted with a 3% fee applied (Visa, MasterCard, Discover, AMEX). To avoid this fee we accept Cash, Debit Card, and Check. In addition we also accept Cherry and Care Credit. *

I have read and accept the financial policy.

Signature(s) of Financial & Medical Decision Maker(s) *

Clear Signature

Date *

Online Forms

Agency Owned Animal Form