Thank you for giving us the opportunity to care for your pet(s).
So that we may become better acquainted, please fill out the following: 

Client Information                                                                       Date_____________

All fees are due at the time of service.  We will gladly provide a written estimate.  

Why did you choose our hospital?        Yellow Pages        Used Service Before         Web Site          Hospital Sign

Please indicate choice of payment:    Cash     Check     MasterCard/Visa

Personal Referral – Whom may we thank?_____________________________

  We strive to protect your personal and financial information. Our computer systems are password protected, and we limit access to your information to necessary personnel. We will not release any information to a third party except for collection purposes, or to help return your lost pet. We also generally consider your pet’s medical information confidential; however, we will release vaccination information to public health authorities, boarding kennels, grooming facilities and other veterinarians.

Signature_____________________________________________________________

Pet History

Has your pet been under the care of another veterinarian?__________________________

Any previous serious illnesses or surgeries? ____________________________________

Any allergies to vaccinations or medications? ___________________________________