Welcome
Thank you for allowing us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To ensure the best care possible, please take a few moments to print and bring in the completed form to the office with you.
Name: Last_________________________  First___________________ Int._________________ Title_________
 

Address___________________________ City_________________ State:______ Zip_____________
 
Phone: Home_______________    Work___________________    Cell/Pager______________________
 
SS#_______________________    License#/State_______________________
 
Employer:______________________________    Employer Address_______________________________

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Pet Information

Patient Name:____________________    Birth Date:___/___/____                         Species:  □ Dog       □ Cat                          

□ Male   Neutered: Yes □   No □                  □  Female    Spayed:  Yes □    No □

Breed:________________________  Color:____________________

Vaccination History: Name & Phone # of  Previous Clinic:__________________________________________                   Date and Type of  Vaccinations:____________________________________________________________
Please Check  any of the symptoms or problems you have noticed in your pet:
Coughing  □ Limping   □  Scooting  □  Shaking Head □
Scratching/ Chewing  □   Lethargic  □    Depressed      □    Weight Loss □  
 Loss of Balance   □ Behavior Problems □ Eating more/less than normal   □  Weight Gain □
 Sneezing    □   Vomiting   □   Drinking more/less than normal   □             
Diarrhea     □  Gagging          □ Hair Loss □    
Other not listed:________________________          
Pet's Current Medication:_________________        
Describe Pet's Diet: Dry:___________________  Canned:_______________  Moist:______________
Frequency:_________________________

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Authorization   

   FULL PAYMENT IS DUE AT TIME OF SERVICE

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the  treatment of  this animal. I am aware that a deposit may be required for treatment.

Payment Method : □ CASH    □ CHECK    □ VISA       □ MASTERCARD     □ OTHER___________

Signature:_______________________________________ Date:______________________________