Name
*
Your First Name
Last Name
Your date of birth (AR law requires us to report the client's DOB when dispensing controlled medications to pets)
*
Spouse / Significant Other
DL#/State
*
Cell Phone#
*
Spouse's Cell Phone #
Home Phone #
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Employer
Employer's Phone
May we have permission to post photos of your pets on Facebook/Instagram?
Yes
No
If you have ALREADY made an appointment, what is the date of your appt?
-
Month
-
Day
Year
Date
PET HEALTH HISTORY
Name of pet
*
Type of pet
*
DOG
CAT
Other
Sex
*
MALE INTACT
MALE NEUTERED
FEMALE INTACT
FEMALE SPAYED
Breed
*
Color
*
Birthdate or age
*
Reason for visit
*
For additional pets: put name, type of pet, sex, breed, color, and age.
Location of pet's previous records?
We can contact your previous vet for for records if you provide us with their name and location.
AUTHORIZATION
*
I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS. I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION.
SIGNATURE
*
DATE OF SIGNATURE
*
/
Month
/
Day
Year
Date
METHOD OF PAYMENT
CREDIT CARD
CHECK
CASH
CARE CREDIT
SCRATCHPAY
Submit
Should be Empty: