WELCOME

Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions about your pet’s health.

To insure the best care possible, please take the time to fill in this form completely. Thank You.

If recommended, by whom? _______________________________________________________________________

Number of pets: Dogs_____________________ Cats _________________ Other (specify) ____________________

Reason for visit _________________________________________________________________________________

PET HEALTH HISTORY

Name of pet_________________________ (circle one) Dog Cat Other_________________

Breed _________________________ Color_____________________________ Birth date______________________

(Circle all that apply) Male Neutered Female Spayed

Vaccination History (date and type of last vaccinations) _________________________________________________

Describe your pet’s diet __________________________________________________________________________

_____________________________________________________________________________________________

Pet’s current medication__________________________________________________________________________

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AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all

charges incurred in the care of the animal. I also understand that these charges will be paid at the time of release and that a

deposit may be required for surgical and emergency treatment.

Signature of Ow style='mso-spacerun:yes'>            Credit Card Other _______________ner___________________________________________________________ Date_________________________

Method of payment (circle one) Cash Check