Form Builder

filter comments

note1

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information that we will need as we support your pets needs today and in the future.

Owner's Name (First & Last)

Spouse/Other

Children & Visitor Names

Address

City

State

Zip

Mobile Phone

Home Phone

Email

Employer

Work Phone

Spouse/Other Employer

Spouse/Other Work Phone

At what time and at what phone number may we call to talk to you about your pet?

Who should we ask for?

Alternate Emergency Number

How / Why did you select us?

note2

Financial Responsibility:

We will gladly prepare a written estimate if you desire (please ask our doctor or receptionist). This will be important to you as we understand that the examination fee is incurred at the time the pet is examined and that all charges must be paid in full at the time services are provided when the pet is discharged/released.

In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge we take Master Card, American Express, Visa, Discover, Care Credit and Compassion Finance.

I assume responsibility for all charges incurred in the care of my animal(s). I also understand that these charges will be paid in full at the time of release and that a deposit may be required for treatment.

I accept.

Today's Date

note3

Informed Consent:

To prevent the spread of infectious diseases, all hospitalized, boarded, or dropped off 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 discharged invoice. These vaccinations for dogs include Bordetella, rabies and Parvo. For felines it is Rabies and FVRCP/C.

I, being responsible for the above described animal(s), have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet(s).

I agree & accept.

Today's Date

Note4

Request for Release of Medical Records:

I, being responsible for the above described animal(s), have the authority to grant you my consent to release my animals’ medical Records to any veterinarian facility. Request for release of records to any other entity must be in writing by the owner.

I agree & accept.

Today's Date

PATIENT INFORMATION

Pet's Name

Species

Breed

Sex & Spayed/Neutered?

Date of Birth / Age

Description

Can you provide any drug or medication information for your pet?

Any physical abnormalities?

If your pet(s) travel (or have traveled) out of the area, where?

Appointment

Do you have an appointment? If so, at what time.