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 will be necessary as we support your pet's needs today and in the future.

Name *

Spouse / Other Name  

Address *

City / State *

Zip Code *

Home Phone  

Cell Phone  

eMail Address  

Employer  

Spouse / Other Employer  


May we call you at work? If so, please give :



Work Phone  

Spouse / Other Work Phone  

How / Why did you select us?  

Yellow Pages
Referred by Friend / Family Member
Previous Client
Drove By
Website
Other


If Other, please elaborate  

If by referral, whose account may we credit?  

What is the Date and Time of your scheduled appointment?  

PET INFORMATION



Pet's Name  

Birthdate  

Color  

Breed  

Sex  

Male
Female


Spayed / Neutered  

Yes
No




Medical Information - Please give the last dates for the following vaccinations / tests:



DOGS



Rabies  

Distemper  

Parvo  

Heartworm Test  

Fecal Exam  



CATS



Rabies  

Respiratory Complex  

Leukemia  

Fecal Exam  




Do you use any type of flea control? If so what type?  

Do you have pet insurance? If so, with what company?  

Is your dog on heartworm medication?  

Any allergies or past serious injuries?  



PAYMENT POLICY

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. If you require an estimate, we will gladly prepare a written estimate for you (please ask our doctor OR receptionist). In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we take Master Card, Visa, Discover, American Express and Care Credit. WE DO NOT BILL so if there is a problem with payment please discuss it with us before hand.

Signature of Responsible Agent for Pet:_____________________________________________ Date:_____________
1. Security Code: *
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