Employer’s Name and Address___________________________ Work Phone________________
Emergency Phone___________________ Referred By:_______________________________
NEW PET / PATIENT INFORMATION
Pet’s Name____________________________________ Date of Birth ____________________
Breed____________________ Color__________ Sex______ Neutered/Spayed?_____________
DATE OF MOST RECENT VACCINATIONS AND MEDICAL HISTORY
DOGS Rabies_______________ CATS Rabies__________________
DHLP+P_____________ FVRCP_________________
(distemper-parvo) (feline distemper combo)
BORDETELLA_________ FELV___________________
(kennel cough) (feline leukemia)
OTHER_______________ OTHER__________________
DOGS & CATS Where was your pet last seen for vaccinations_______________
Is your pet currently on Heartworm Prevention?_________
Date of last H/W Test____________
Is your pet currently on any Flea Prevention? Type?
_____________________________________________
Please list any food or drug allergies or sensitivities:
_____________________________________________
Please list any current medications:
_____________________________________________
PAYMENT IS DUE AT THE TIME OF SERVICES, BEFORE THE PATIENT IS RELEASED.
I am financially responsible for the pet/patient described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by risk, and that it is not possible to guarantee the successful outcome of any such procedure. This agreement is in force indefinitely from this date unless I notify the clinic in writing to the contrary.
Method of payment: Cash________ Check________ Credit Card___________________________________________
Signature of Responsible Party_________________________________________________ Date___________________
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