Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

If needed, can we call you at work?

Yes
No

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of last exam

If you have a previous Veterinarian, pelase list their Clinic/Dr. name

Where did you get your pet?

How long have you owned your pet?

Is your pet fed any table scraps (people food?)

How much time does your pet spend outdoors in an average week?

Where does your pet sleep?

Do you have children in your home? If so, what age are they?

If your pet is not spayed/neutered, do you plan to have it done?

Do you plan to breed your pet?

What prior illnesses or injuries has your pet had?

Does your pet have any drug allergies?

Have you medicated your pet recently? (include over-the-counter drugs)

If yes, state medications:

Do you take your pet with you on vacation?

Will you ever need to board your pet?

Does your pet spend long periods of time alone during the day? □ Yes □ No

Does your pet spend time in forested areas or cottage country?

Is your pet on a preventative program for controlling external parasites (fleas, ticks and mites)?

Is your pet on a preventative program for controlling internal parasites (heartworm, roundworm, hookworm, etc.)?

Has your pet been microchipped or tattooed?

Do you understand the health benefits and life extending effects of providing proper dental care for pets?

Do you have pet insurance?

Check any of the following that are of concern to you regarding your pet's behaviour/health:

Please elaborate:

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Dat of last exam:

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of last exam:

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Dat of last exam:

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of last exam:

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your pet. We accept all major credit cards (VISA, MasterCard, American Express), and cash payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

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