Patient/Client Information

 

Thank you for giving us the opportunity to care for our pet.  Please help us better meet your needs by taking a few moments to fill out this information sheet.

_______________________________________________________________________________________________

 

 

 

 

Your Name__________________________________________________________________________

 

Address ___________________________ City_____________ State_________ Zip___________

 

Phone   Home (___)______________  Work (___)____________ Cell (___)__________

 

E-Mail _____________________________________________________________________________

 

Employer’s Name & Phone # __________________________________________________________________________________

 

Spouse/Other _______________________________________________________________________

 

Spouse/Other’s Employer Name & Phone # __________________________________________________________________________________

 

At What Time____________________ And At What Phone # _____________________ Is It Best To Call About Your Pet?

 

In Case of EMERGENCY, Call _________________________________ At Phone # __________________

 

We will gladly prepare a written estimate if you so desire.  Please ask the receptionist or doctor.  Professional fees are due at time services are rendered.

 

Preferred Method of Payment:  () Cash      () Check     () Credit Card

 

Name of Previous/Current Veterinarian_____________________________________________________

 

How did you hear about us?

 

¨  Referred by the American Animal Hospital Association              ¨ Hospital sign

 

¨ Yellow Pages ad                                                                      ¨ Individual

Name___________________________

 

How Would You Like To Be Reminded of Future Recommended Preventive Health Care Services For your pet?

 

 (   )   Phone   (   )  Mail   (   )  Both Phone & Mail

 

 

 

 

Continued on next page…

 

 

Animal Medical History

 

 

Please complete information for all your pets - Thank You!

Pet

#1

Pet

#2

Pet

#3

Pet’s Name

 

 

 

Species (Dog, Cat, Bird, etc.)

 

 

 

Breed

 

 

 

Description (Color and Markings)

 

 

 

Age or Date of Birth  (Approximate)

 

 

 

Sex

M - F

M - F

M - F

Neutered or Spayed?

Y - N

Y - N

Y- N

Diet (Name of Your Pet’s Food)

 

 

 

Daily Medications, Vitamins or Treats

 

 

 

Shampoo/Flea Products Used

 

 

 

Hours Spent Outside Each Day

 

 

 

 

Vaccinations

Please note the dates the following vaccines/tests were given.

         Pet #1                                     Pet #2                             Pet #3

DOGS:

        DA2LPP (Distemper/Parvo )

 

 

 

        Bordetella (Kennel Cough)

 

 

 

        Corona (Dogs)

 

 

 

        Heartworm Test (Dogs)

 

 

 

        Rabies

 

 

 

            Other Vaccines - Please Specify

 

 

 

CATS:

         FVRCP (Infectious Diseases)

 

 

 

             FIP (Feline Infectious Peritonitis)

 

 

 

             Rabies

 

 

 

         Other Vaccines - Please Specify

 

 

 

         FELV (Feline Leukemia)

 

 

 

             FELV Test or FIV Test? (Cats)

 

 

 

 

 

 

 

 

Continued on next page…

 

 

 

 

 

Fecal Test (Stool Exam for Worms)

 

 

 

Dentistry (Approx Date Work was Done)

 

 

 

Geriatric Health Screen  (Approximate)

 

 

 

Medical History - Prior Illness/Surgery:

 

 

 

 

 

 

                                                                                                                                                   

 

 

Please Sign Below

 

To help prevent the spread of infectious diseases, hospitalized and boarded animals must be current on all Vaccinations.

 

DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION.  Vaccination can be updated at the time of your appointment if it is not current.

 

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling.  I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above and additional pets I present.  Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated.  I agree to pay all collection agency or attorney fees in the event that my account becomes delinquent for 30 days or more and the account is placed with an outside collection agency or attorney.  All accounts 30 days past due are subject to a 5% late fee per month.  I understand that a service fee of $30.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent.  I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge.  Continuous presence of qualified personnel may not be provided.  If I fail to pick up <animal> within 5 days of the discharge date and do not notify Animal Ark Veterinary Clinic, PC within that time period, Animal Ark Veterinary Clinic, PC  may assume that <animal> is abandoned and are hereby authorized to make alternate arrangements for the care or disposal of <animal> as Animal Ark Veterinary Clinic, PC  deem best and/or necessary.  Additionally, I will be responsible for any boarding/hospitalization charges incurred during that period and any and all disposal fees.  My signature is acceptance to these terms and constitutes and an agreement.

 

 

Signature_____________________________________ Date _______________________

 

                                       

 

Healthy Pets Make Us Happy!

 

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