Owner Contact Information

Your Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Primary Phone *

Alternative Phone *

Email *

Work # (in case of emergency)

How were you referred to us?: *

Other *

Would you like to add your spouse or a co-owner? *

Yes
No

Pet's Information

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Pet Name *

Breed *

Type of pet *

Age/Date of Birth *

Color *

Sex *

Where did you obtain your pet? *

Other *

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What is your pet's diet? *

What date did your pet receive these vaccinations *

Reason for visit *

Any previous serious illnesses or surgeries? *

Assessing Your Pet’s Health Risk

Have you introduced or do you intend to introduce a puppy, adult dog, kitten or cat into your household? *

Yes
No

Do you have more than one dog or cat in your household? *

Yes
No

Is your pet allowed to go outside or come in contact with other animals? *

Yes
No

Do you take your pet to the beach or park? *

Yes
No

Do you professionally groom, show or board your pet? *

Yes
No

Do you take your pet hunting, swimming or hiking in areas with increased exposure to ticks, wildlife or access to rivers or streams? *

Yes
No

Do you have young children in your home? *

Yes
No

Are there any children or adults in your home that are immune compromised from such diseases as diabetes or cancer therapy? *

Yes
No

Agreement

Treatment Authorization and Information *

I HAVE READ THE PREVIOUS STATEMENT AND AGREE TO THE TERMS.

We will gladly prepare a written estimate of service fees if you desire (please ask your doctor or receptionist). All professional fees are due at the time services are rendered. We accept cash, check, and major credit cards. In case of extensive medical or surgical procedures, we do require a deposit. We offer Care Credit financing for qualified clients, please ask a receptionist for details. Returned checks are subject to a $20 returned check fee. All balances are subject to a monthly finance charge. If it becomes necessary to send your account to a collection agency, you are responsible for all collection fees incurred. I am the owner or an authorized agent for the owner of the above pet and have the authority to execute this agreement. I authorize the Veterinary Clinic to examine and treat the above pet. I affirm that the above information is accurate and correct. I agree to defend, indemnify, and hold the Veterinary Practice harmless for any claims and injuries that I may have or suffer that arise as a result of, or are caused by, my pet.

Please type your name to agree *

Today's Date *

Do you agree to allow us to share photos of your pet on our social media and marketing materials? *

I agree
I do not agree

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