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.
Children (first name & ages)________________________________________________
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_________
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
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)