Client's Name

First Last

Partner's Name:

First Last

if applicable

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone

Secondary Phone

Email

Pet's Name

Species

Breed

Color

Date of Birth

Sex

Spayed Female
Intact Female
Neutered Male
Intact Male

Microchipped

Yes
No
Unsure

Please list any/all current medications or pre-existing medical conditions below:

Please list any previous Veteriary Hospitals that your pet has been to:

How did you become aware of our veterinary hospital?*

Referred by a current client
Drove by/sign
Website
Social Media

If referred by a current client, whom may we thank?

Authorization*

I agree to the below policy.

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in care of this animal. I also agree to make complete payment at the time services are rendered. I also understand that in the case of non-payment I will be subject to all billing and/or finance charges associated with my account. Should it become necessary to settle my account through a collection agency or attorney, I, the undersigned agree to pay all costs of collections. If you fail to keep your scheduled appointment and do not call with at least 24 hours notice, you will be billed for a missed appointment.

Today's Date

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