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WELCOME

Doctor: ____________

Client Information:

Date______________ Drivers License#_________________ State_______

Name____________________________________________ Spouse________________________________

Street Address___________________________________ City________________ State_____ Zip________

Home Phone(______)_______________ Work Phone(______)________________ Cell(______)_______________

Emergency Contact_____________________________________________ Phone(___)______________

How did you learn about our practice?_____________________________________________________

Primary reason for visit_________________________________________________________________

E-Mail Address: _______________________________________________________________________

Pet Information:

-Pet’s Name__________________________ -Species______________ -Breed_______________________

-Birthdate _____________________ Sex________ -Neutered/Spayed Y N -At what age?_____________

-What age was pet obtained? __________ From: __Friend __Breeder __Pet Shop__ Humane Society

__Other__________________________

-Color________________________________________________________________________________

-Microchipped? – Yes ___ No ___

Describe your pet’s diet_________________________________ Canned__ Dry__ Brand_____________

List your pet’s current medications________________________________________________________

Please check any symptoms or problems you’ve noticed with your pet:

__ Appetite Loss __ Gagging __ Sneezing

__ Behavior Changes __ Gums Bleeding __ Thirst

__ Breathing Problems __ Limping __ Urination Increase

__ Coughing __ Loss of Balance __ Vomiting

__ Depression __ Scooting __ Weakness

__ Diarrhea __ Scratching __ Other______________

__ Eye Disorders___________________ __ Shaking Head __ Other______________

Pet History (check all vaccines that pet has received)

__ Prior Surgery_______________ __ Feline Leukemia Test __ Distemper

__ Prior Illness________________ __ FVRCP (Infectious Disease Cat) __ Parvovirus (Dog)

__ Other ____________________ __ Dental __ Rabies (Dog/Cat)

Statement of Ownership and Consent

I am the owner of the above described animal or I have the authority to consent to its treatment, and I accept all financial responsibility. I hereby authorize the performance of professionally accepted diagnostic, therapeutic, and/or surgical procedures as necessary.

I understand that payment is required upon completion of services and failure to provide payment may result in finance charges being assessed to any overdue balance.

Signature of client responsible for pet(s)______________________________ Date_________________

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