NC/NP 2022 Form

Client and Patient Information

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Name*
Spouse/Co-Owner
Address*

Address

Street Address Line 2

CityState

Zip
E-Mail Address*
example@example.com
Primary Phone Number*
Is your primary phone number a mobile number?*

YesNo
Work Phone Number
Driver's License #
DL Expiration Date:
Employer
Spouse/Co-Owner's Cell Phone Number
Spouse/Co-Owner's Employer & Phone Number
Emergency Contact*
Emergency Contact Phone Number*
How did you become aware of our clinic?*

Web SiteKMUWGoogleFacebookPersonal RecommendationOther
Personal Recommendation (whom may we thank?)
May we have your permission to use your pet's photo on our social media accounts?*

YesNo

	Pet 1	Pet 2
Name
Breed
Date of Birth/Age
Color
Alleriges?
Special diet or medication(s)?
Pet Health Insurance Company?

Previous Medical Records? Previous Clinic Name and phone number:*
I agree to pay any costs and charges necessary for the collection of any amount not paid when due.

A full payment is required upon rendering of services. We do NOT carry open accounts.

We accept the following: Cash, Check , Visa, MasterCard, Discover, American Express, Care Credit, Scratch Pay and Varidi.
Signature of owner or authorized representative:*

Clear
Date:*

MonthDayYear
Date
404 S. Edgemoor, Bldg 100 Wichita, KS 67218
316-683-4641 www.skaervet.com

Please submit form within 24 hours of appointment!

A cancellation fee equivalent to the exam fee will be charged for cancellations within 24 hours. Emergency situations are exempt.

** New clients please have all medical history records for patient emailed or faxed to Skaer Veterinary Clinic within 48 hours of appointment. Your appointment may need to be rescheduled if we do not receive records in a timely fashion.

Records may be emailed to hospital@skaervet.com or faxed to (316)683-0817.

THANK YOU for bringing your pet to our hospital!
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Client and Patient Information