Name *

First

Last

Driver’s License # *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Employer

Work Phone

Preferred Method of Contact *

Email
Phone
Postal Mail

Spouse/Co-Owner Name

First

Last

Spouse/Co-Owner Phone

How did you learn about our practice? *

Notify in case of emergency *

Cell Phone

Work Phone

Pet Information

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify. *

Breed *

Age/Date of Birth *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Diet or brand fed *

How often fed? *

Current medication

Any known allergies or drug sensitivities

Reason for pet’s visit *

Previous veterinarian where we may ask for previous medical records *

Will you allow images of your pet on our website or social media? *

Yes
No

PAYMENT – Read the following carefully and sign below.

PAYMENT IS REQUIRED WHEN SERVICE IS RENDERED. DEPOSIT IS REQUIRED ON ALL HOSPITALIZED ANIMALS. We will gladly prepare a written estimate of service fees if you desire (please ask our doctor or receptionist). We accept cash, major credit cards, and Care Credit. Note: we do not accept checks *

I have read and agree.

I certify that I have ordered, or have been authorized by the owner to order the named services for the above described animal. In any event, I accept full financial responsibility for the payment for services ordered and rendered. *

I have read and agree.

To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines (dogs – Rabies, DHPP and Bordetella vaccines; cats – Rabies and FVRCP vaccines) and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice. *