Name *

First

Last

Preferred Pronoun

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Reason for Visit *

Sex *

Male
Neutered Male
Female
Spayed Female

Is this a referral? *

Referring Veterinarian
Self Referral

Who was the Referring Veterinarian?

Consent that all photographs taken of my pet(s) may be used for the purposes of print, television, video, and web-based advertising, promotion and/or publication on but not limited to social media sites such as Twitter, Facebook, LinkedIn, among others. I understand that only my pet’s first name will be used, and no other identifiable information will be published, and I also understand that there will be no compensation (financial or otherwise) involved. *

I grant permission
I do not grant permission

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 *

Clear Signature

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