Client Information


WELCOME

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we’ll be glad to help you. We look forward to working with you in maintaining your pet’s health.

First Name

Last Name

Initial

Date

Soc. Sec

Driver's License

Address

City

State

zip

Home Phone

Email

Employer

Occupation

Business Address

Business Phone

Spouse or Co owner

Home Phone

Business Phone

How Did you learn about our practice?

Notify In Case of emergency

Home Phone

Business Phone

Pet Information

Pet Name

Pets

DogCatother

If Other Then Tell Us

Birth Date

Sex

MF

Breed

Color

Neutered/Spayed

YesNo

At What Age?

Where did you obtain this pet?

FriendBreederPet ShopHumane SocietyOther

If Other Then Tell Us

At what age was the pet obtained

Pet's history--check (7) all that pet has received:

DHLP (Distemper--Dog)Feline leukemia test (Cat)Rabies (Dog/Cat)Parvovirus (Dog)FVRCP (Infectious diseases--Cat)Dentistry

Describe any:

G Prior illness

G Prior illness

M Prior surgery

M Prior surgery

Reason for pet's visit :

Payment

Please mark (7) how you will be paying for your services today:

MasterCardAmerican ExpressCheck O VisaID DiscoverCashCare Credit

We will gladly prepare a written estimate of service fees if you desire (please ask our doctor or receptionist). All professional fees are due at the time services are rendered. There will be a service charge for any check returned unpaid.

To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice.

Signature of client responsible for pet(s)

Date