CLIENT INFORMATION

Name:

Spouse's Name

Children (first name, age):

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Work Phone:

Cell:

Spouse's Work:

Emergency Contact (Name & Phone):

Place of Employment:

Best time to reach you:

at

Email

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
Animal Medical Center accepts the following forms of payment: Cash, Check, Visa, Mastercard, CareCredit. Unpaid accounts will be assessed a $3.00 per month accounting fee at the end of each month plus a 1.5% monthly charge.

AUTHORIZATION
I hereby authorize Animal Medical Center veterinarians to examine, prescribe for, or treat the pet(s) listed. I assume full responsibility for all charges incurred in the care of my pet(s). I also understand that fees are due at the time of service and that deposits may be required for hospitalization or surgical procedures.

Signature

Clear Signature

Date

I authorize pertinent medical history information regarding my pet(s) to be released to the following:

How did you become aware of Animal Medical Center:

Whom may we thank?

Do you have veterinary insurance for your pets?

Yes
No

If yes, name of company:

PATIENT INFORMATION

Pet 1

Name:

Breed:

Species

Other

Color:

Date of Birth

Gender

Male
Female

Is your pet:

Neutered
Spayed

Any previous illnesses or surgeries:

Allergies to vaccines or medications:

Is your pet on any special diet or medications:

Do you have a second pet?

Yes
No

Pet 2

Species

If other, please specify:

Any previous illnesses or surgeries:

Allergies to vaccines or medications:

Is your pet on any special diet or medications:

Do you have a third pet?

Yes
No

Pet 3

Species

If other, please specify:

Any previous illnesses or surgeries:

Allergies to vaccines or medications:

Is your pet on any special diet or medications:

Client Contact Form