E-Mail Address (required) : Preferred Method of Contact (required) How did you hear about us? (required) How did you hear about us (if you answered "other") Authorization: By submitting this form, I hereby authorize the doctors and staff to diagnose, prescribe for, and treat the pet described below. I assume all responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time services are rendered. In the case of hospitalization, I will be required to leave a substantial deposit. The remaining balance must be paid in full at the time of discharge of the pet. I authorize photos and video to be taken of my pet's care for training, website, and educational purposes.
Please present a valid drivers license or photo ID at the time of check-in. Financial Information: How do you plan to pay for today's visit? (required) Do you have pet insurance? If not, we'd be happy to tell you more about how pet insurance can help! Pet's Name (required) Approximate Age. Years/Months (required) Type of Pet (required) Breed or Mix: (required) Sex: (required) Color: (required) Is your pet spayed (females) or neutered (males)? (required) Does your pet live indoors, outdoors or both? (required) Where did you get your pet? (required) When did you get your pet? (required) Pets approximate age when acquired? (required) Is your pet Microchipped? Has your pet ever visited a veterinarian before? If so, approximate date of last examination? (required) Last vaccination Dates: Please list other veterinarians your pet has visited: (required) Please list any other pets you currently own: Kindly list any previous medical or surgical problems and current medications: Is your pet currently receiving any Heartworm Preventative? (required) Brand Name (of Heartworm preventative) What Flea & Tick preventative are you currently using on your pet(s)? (required) What brand of food is your pet currently eating? How much do you feed him or her daily? (required) Does your pet get any table scraps? If so, approximately how often? (required) Describe your pet's temperament (personality) : (required) Reasons or conditions that prompted your visit? (required) Authorized Representatives: The individuals listed below are authorized representatives to act on your behalf in cases dealing with the pet listed above. They are authorized to obtain medical information regarding your pet, to admit and pick up your pet from our facility, and give verbal and/or written authorization to perform medical services and procedures. The individuals listed below are required to show photo identification when acting as your authorized representative. Authorized Representative #1 (Full name, relationship to you, and phone number) Authorized Representative #2 (Full name, relationship to you, and phone number) Authorized Representative #3 (Full name, relationship to you, and phone number)
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