Registration

Owner's Name*

First Last

Spouse/ Other

First Last

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your physical address different from your mailing address?

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone

Spose/ Other Phone

Email*

Employer Name

Employer Phone

How did you hear about us?

Internet Search
Flyer
Hospital Sign
Family/Friend

What method of contact do you prefer for your pet's reminders?

Phone Call
E-mail
Mail
Text Message

List any additional family members, friends, ect that you authorize to handle your pet when you are not present (ex: bringing in, dropping off or picking up from appointments, boarding, or treatments. We may need to have you fill out an Agent Authorization form if not an immediate family member.

Name

First Last

Association

Phone

Add Another Person?

Add another person

Name

First Last

Association

Phone

Pet Health History

Pet's Name*

Date of Birth/ Age

Type of Animal

Dog
Cat

Sex

Male
Male Neutered
Female
Female Spayed

Breed

Color*

Weight

Has your pet been seen by a veterinarian?

Yes
No

Received Vaccines?

Yes
No

When is your pet scheduled for an appointment?

Time

:

Add another pet?

Add another pet

Pet Health History #2

Pet's Name*

Date of birth/ age*

Type of animal

Dog
Cat

Sex

Male
Male Neutered
Female
Female Spayed

Breed

Color*

Weight

Has your pet been seen by a veterinarian?

Yes
No

Received Vaccines?

Yes
No

When is your pet schedule for an appointment?

Time

:

To help prevent the spread of infectious diseases, hospitalized and boarded animals must be current on all vaccinations.

DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION. This vaccination can be updated at the time of your appointment if it is not current.

I understand every effort will be made to achieve a successful outcome and 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 in this information sheets and any 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 $25.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. I understand that 24-hour emergency services are available, and that emergency services performed outside of normal business hours are subject to emergency service rates. If I neglect to pick up my pet(s) within 5 days of the discharge date and do not notify you within that time period, you may assume that the animal(s) is/are abandoned and you are hereby authorized to dispose of the animal(s) as you deem best and/necessary.

** IN THE EVENT OF A HURRICANE EVACUATION, YOUR PET(S) MUST BE PICKED UP WITHIN AN HOUR OF ISSUANCE OF A MANDATORY EVACUATION, OR YOU MUST CALL US TO MAKE OTHER ARRAINGMENTS. WE WILL NOT HAVE STAFF ON PREMISES TO CARE FOR YOUR PET(S) DURING A HURRICANE REQUIRING EVACUATION. **

Do you give Animal House Veterinary Hospital authorization to use your pet's photo for social networking websites such as, but not limited to our website, Facebook, and/or Twitter?*

Yes
No

Signature*

Comments

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New Client Form

Registration

Pet Health History

Pet Health History #2

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