Patient/Client Information           Date:______

Thank you for giving us the opportunity to care for your pet.  Please help us meet your needs better by taking a moment to complete both sides of this information sheet.  We would appreciate your comments about making our practice better if you would write them in the shaded area at the bottom of this sheet.

 

Owner’s Name________________________Spouse/Other________________________

 

Children (first name & ages)________________________________________________

 

Address_____________________City_____________State/Prov._____Zip/PC_______

 

Home Telephone____________________Work Telephone________________________

 

Employer’s Name & Address________________________________________________

At what time_______and at what phone number_________is it best to call about your pet

 

In case of EMERGENCY, please call________________at telephone number_________

 

We will gladly prepare a written estimate if you desire.  Please ask the receptionist or Doctor.  Professional fees are due at the time services are rendered.  In the event that your account is not settled at the time services are rendered, you will be charged a monthly billing fee, and interest at the maximum legal rate as well as any collection costs incurred.   Social Security #__________________________________   Drivers License Number ________________________State/Prov.___________________   Signature___________________________________________

 

How did you first hear of our hospital?

q Individual; someone we may thank?_______________ 

q Hospital sign

q Yellow Pages under location

q Yellow Pages under service

q Other_________________________

We consider our pet(s):(circle)   part of the family    or     just as pet(s)

 

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites.  I authorize the Doctor to provide vaccines and parasite control as needed for my pet.________________(initial)