Thank you for choosing our hospital to care for your pet. We look forward to serving you
and your pet. In order to do so, we would appreciate some background information on you
and
your pet. Please print this page and return it to us in your first visit.
CLIENT
Name _____________________________________________________
Telephone # (H) ____________________ (W) _____________________ (C) _____________________
Address ___________________________________________________
City _____________________
State __________ Zip code __________
In order to write a check: DL# _______________________________
email address
How did you hear about us? ___________________________________
PET DESCRIPTION
Name _____________________ Dog or
Cat ___________________
Breed _____________________
Coloring _____________________
DOB ______________________
Male or Female _______________
Spayed or Neutered ___________
Please
note any symptoms your pet is showing: ____________________
_____________________________________________________________
Please provide us with a copy of your
pet's vaccines from your regular vet.
* Payment
is expected at the time services are provided. A $35.00
service charge will be applied to
all returned checks. Unpaid balances
over 90 days will incur a 35% collection fee.*
________________________________________________
__________
signature of owner
date
