All Creatures Animal Hospital



All Creatures Animal Hospital

New Client Registration Form

Client Information

Please print

Client (Owner) Name: ____________________________________

Significant other/Alternate Caretaker: _________________________

Street Address: _________________________________________

(please include apartment/unit numbers)

City: _________________ State: _______ Zip Code: ____________________

Home phone: _______________ Cell phone: ________________________________

E-mail address: _______________________________________________________________________

(your e-mail will only be used for updates, special offers, appointment confirmations, and reminders).

Occupation: ___________________________________________

Employer address: ___________________________________________________________________

Birthdate: __________ Preferred method of contact:______________

Do you have pet insurance or Care Credit?: ______________________

How did you hear about our hospital?(please check one or fill in)

Drive-By: ______ Yellow Pages: ______ Facebook: ______

Internet (please specify): ____________________________________________________________

Friend referral: _______________________________________________________________________

Pet Store (please specify): ___________________________________________________________

Other (please specify): _______________________________________________________________

Patient Information

Please give us some information for each of your pets.

1. Pet’s Name: _______________________ Gender: _____________________

Spayed/Neutered?: ___________ Species: ____________________________________

Breed(s): _________________ Color(s): _____________________________________

Age or birth date: __________ Microchip/Tattoo: ____________________________

Date of most recent Rabies vaccination: __________________________________________

Pre-existing medical conditions, known allergies, or other important information about your pet: ________________________________________________________

__________________________________________________________________________________________

2. Pet’s Name: _______________________ Gender: _____________________

Spayed/Neutered?: ___________ Species: ____________________________________

Breed(s): _________________ Color(s): _____________________

Age or birth date: __________ Microchip/Tattoo: ________________

Date of most recent Rabies vaccination: ________________________

Pre-existing medical conditions, known allergies, or other important information about your pet: ________________________________________________________

__________________________________________________________________________________________

3. Pet’s Name: _______________________ Gender: ____________

Spayed/Neutered?: ___________ Species: ____________________________________

Breed(s): _________________ Color(s): _____________________________________

Age or birth date: __________ Microchip/Tattoo: ________________

Date of most recent Rabies vaccination: __________________________________________

Pre-existing medical conditions, known allergies, or other important information about your pet: ________________________________________________________

__________________________________________________________________________________________

If you need more room to add more pets, please use the back of this page.

Thank you for choosing All Creatures Animal Hospital. Our hospital treats dogs, cats, and many other small animals. We offer vaccines, wellness exams, many various surgeries, pain management, and much more. We have in-house diagnostic tools including blood analysis machines and digital x-ray equipment. Our hospital also offers boarding for dogs, cats, and some small animals. Patients may be seen by scheduled appointments or walk-ins. Our weekday appointment and walk-in times are from 9:00 AM to 10:30 AM, and 2:30 PM to 5:30 PM. On weekdays we have scheduled surgery times from 11:00 AM until 2:30 PM and we do not see appointments or walk-ins during that time. On Saturdays, we take appointments and walk-ins from 9:00 AM to 11:30 AM. We are closed on Sundays. We have certain policies in place to facilitate the function of our hospital and to ensure the best care possible for our clients and patients.

PLEASE READ CAREFULLY

1. We do not accept checks and we do not offer payment plans.

a. Payments for services and products are due in full at the time services are rendered.

2. All boarding animals must be up-to-date on all vaccines, tests, and parasite prevention according to our hospital policy.

3. According to state law, medications CANNOT be prescribed to a patient without first receiving an exam from the doctor, and prescription items (medications, parasite prevention, and food) CANNOT be returned or exchanged, NO EXCEPTIONS.

a. Some medications require regular blood testing before prescribing or refilling.

b. A prescription fee of $5.00 is charged for outside prescriptions or medications. This includes Wal-Mart pharmacy, Publix pharmacy, 1-800-Pet Meds, Fosters & Smith, etc.

c. Prescriptions must be picked up by the owner or authorized caretaker

4. Patients using heartworm prevention products must get a heartworm test every year and provide proof if done outside of our hospital.

5. If any accounts are sent to collections there will be a 40% additional fee added to the total bill.

6. Please notify our staff of any possible payment issues, financial restrictions, and special preferences or requests prior to your appointment. This will help us serve you better.

I herby give permission for my pet(s) to be treated as deemed best by the staff veterinarian in case of accident, injury, escape, or death of my pet(s). I assume full responsibility for the expenses involved with necessary treatments. I am aware that the best care could involve my transport of my pet(s) in order to be treated or watched during illness or recovery. I am aware that the staff veterinarian will use all responsible precautions against accident, injury, escape, or death of my pet(s). The clinic and staff in no way will be held liable for any problems which may develop, providing reasonable care and precautions are followed.

Client Name (printed):______________________________________________________________

Client Signature: ____________________________________________ Date: __________________

Your signature indicates that you have read and agree to the policies as outlined above, and that the information provided in this form is legitimate and factual.

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