Owner's Name* First Last Primary Phone*Spouse/Other: First Last Spouse/Other Primary Phone**THE PEOPLE LISTED ABOVE ARE PERMITTED TO ACQUIRE ANY/ALL INFORMATION ON PATIENT(S)**Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code In case of EMERGENCY and we cannot reach you at the numbers listed above. Who can we call?Name* First Last Relation* Phone*Email Address (Notification yearly vaccines due, etc. Via e-mail):* Name of Previous/Current Veterinarian:* Previous/Current Veterinarian Phone:*How did you hear about us? Individual/Someone We May Thank Another Hospital? Who can we thank?* Which hospital?* To help prevent the spread of infectious diseases, it is hospital policy that ALL hospitalized and boarded animals must be current on all vaccinations.* I understand 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 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 on the reverse side 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 for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $30.00 will be assessed for each non-sufficient funds check and/or certified letter that must be sent. I understand that veterinary service is provided during night-time hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to dispose of the pet as you deem best and/or necessary.* I understand Animal Medical HistoryPet’s Name:* Date of Birth/Approximate Age Species:* Dog Cat Sex* Male Female Please select:* Indoor Outdoor Both Breed* Description/Color:* Is your pet spayed or neutered?* Yes No Vaccine History (Please select all that apply)* Rabies Distemper Kennel Cough (Bordetella) Lyme Canine Influenza Heartworm Test Fecal Test (Stool Exam for Worms) Please specify an approximate date for each vaccine you selected above*Vaccine History (Please select all that apply)* Rabies Distemper Leukemia Vaccine Leukemia Test (FELV/FIV Test) Fecal Test (Stool Exam for Worms) Please specify an approximate date for each vaccine you selected above*Please list any other major medical history such as dentistry, Geriatric Health Screen, Major Illnesses/Surgeries, etc.Procedure:Approximate Date Diagnosis/Work Done Signature*Date* MM slash DD slash YYYY CAPTCHA Δ
