NCIS

Kimberly Crest Veterinary Hospital & Specialty Services
Thank you for giving us the opportunity to help care for your companion. Please help us become better acquainted by proving the required information below.
Primary Contact (The person we will contact first)

First Name Last Name
Birth Date

Month Day Year
Date
Cell Phone
Home Phone Number (if applicable)
What phone do you prefer we call first when trying to contact you?

Home number Cell Number
Employer
Employer: Work Phone
Can we contact you at work for non-emergencies?
Secondary Contact (The person we will contact second)

First Name Last Name
Relationship to Primary Contact
Secondary Contact: Cell Phone
Secondary Contact: Employer
Secondary Contact Employer: Work Phone
Can we contact them at work for non-emergencies?
Address

Street Address

Apartment/Building #

City State / Province

Postal / Zip Code
Email Address
example@example.com
Driver's License #
Note: It is not mandatory to give us your driver's license number. However, without it, we are unable to take personal checks
How did you become aware of our hospital?

Individual I was referred by another veterinarian Yellow Pages Hospital Sign Humane Society Internet or Website Our Brochure Facebook
SOCIAL MEDIA CONSENT:
We here at Kimberly Crest are very proud of our patients and we like to show it! We use Facebook, Pinterest, and Instagram to stay connected with our clients and show off our amazing patients. If you are okay with us sharing your companion's photos and experiences here at the hospital, please let us know below!!! *We will never share your personal information and you have the right to revoke this approval at any time*
Yes, I consent to allow Kimberly Crest Veterinary Hospital to share my pet's photos and information on social media. No, I would prefer my pet's photos and information not be shared on social media.
Are there medical records you would like transferred from another veterinarian's office/were you referred to us by another clinic?
If yes, Clinic Name
Doctor's Name (if known)
PET

Please list the information of the pet that we are currently seeing. We can add additional pets at a later time
NAME
BREED
COLOR
AGE/DATE OF BIRTH

Month Day Year
Date
SEX

MALE FEMALE NEUTERED MALE SPAYED FEMALE
CURRENT MEDICATIONS (INCLUDING HEARTWORM AND FLEA PREVENTION)
DOES YOUR PET HAVE A TATTOO OR MICROCHIP?

YES No
WHAT FOOD DOES THIS PET EAT?
Do you have Pet Insurance?

Yes No
Pet Insurance Company Name
Policy # (if known)
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Outstanding balances witl be subject to a 1.5% monthly service charge (18% APR) a fee of $2.85 monthly. Any account requiring collection activity will also be subject to reasonable cost of collection and all legal fees addition intobilling and court costs. A return check fee of $30 per return will be charged for any returned check. I understand every effort will be made to achieve a successfuloutcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe, treat or perform surgery upon pet(s) listed. I am 18 years old and I agree to the terms and conditions and have provided all of the required information.
Should be Empty:

Kimberly Crest Veterinary Hospital & Specialty Services

SOCIAL MEDIA CONSENT:

PET