Welcome Form - MRAH at 96th Street

Welcome to Michigan Road Animal Hospital at 96th Street!
Thank you for giving our pet loving team the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To ensure the best care possible, please take the time to fill in this form completely. Thank You!
Today's Date: *

Month Day Year
Date
Requested Date Of Your Pet's Appointment: *

Month Day Year
Date
Owner's Name *
First and Last name
Primary Contact Number for your account: *
Cell Phone:
Home Phone:
Work Phone:
Address *

Street Address

Apartment or Suite #

City State

Zip Code
Date of Birth of Pet Owner (responsible party/owner must be 18 years old) *

Month Day Year
Last Four Digits of SSN:
Employer Name:
Additional Owner / Co- Owner
First and Last Name
Contact Number for Additional Owner / Co-Owner
Additional Contact Number for Additional Owner / Co-Owner
Email Address
example@example.com
Please provide us with your email. In doing so you'll get invited to use our Pet Desk app - earn rewards to use towards future visits, access your pet's records, make appointments, send us requests for refills and more. We'd love tell you more about it!

By providing your email we are also able to contact you with changes to our hours, operating policies, procedures and more when necessary.

Additionally, your email address is what you can use to login and shop our online store for medications, food, and more for your pet. Thank you! 🐾
Driver's License Number & State Issued
For your convenience, please provide your Drivers License number. This will alleviate future requests if you plan to pay by check.
Were you referred to us by a current client? We'd like to send them a Thank you!
First and Last Name of Referrer
If you were not referred by a current client of ours, please let us know how you find out about our hospital for your pet's care.

Hospital Sign/Drove By American Animal Hospital Association (AAHA) Our website (www.indyvets.com) I am a previous client. AKC Other
If we take a picture of your pet, do we have your permission to use it on our social media sites? We would not share your name or other personal information. *

Yes, please do! No, thank you.
PET INFORMATION:
Pet Name *
Species: *

Canine Feline
Breed: *
Color *
Birthdate

Month Day Year
Date
Sex *

Male, intact Male, neutered Female, intact Female, spayed Unknown
Is your pet microchipped? *

Yes No No, but I'm interested in getting this done. Tell me more!
Do you have health insurance for your pet? *

Yes - please let us know which company in the next box. No. No - but I'm interested in learning more!
If you answered yes to the above for your pet - please list your pet's provider.
We utilize Trupanion Express at our office to help expedite claims for those insured with Trupanion. Please let us know if you'd like us to do so!
Name of Previous Veterinary Hospital/Clinic *
What will we be seeing your pet for? What concerns do you have about your pet? *
If your pet has previous medical history, we would like to have a copy of it to complete your pet's record with us prior to the appointment.

If you have a digital copy of your pet's medical records, please email it to indyvets@indyvets.com at this time, if it hasn't been sent yet. You can also text us any images of medical history to 317-228-0645. Thank you!
Does your pet have any known allergies? *
Has your pet ever had a reaction to vaccines or medications? *
Is your pet on any medications or supplements?
Is there anything else you'd like to share with us about your pet? (Personality, likes, dislikes, etc)
Second Pet
Do You Have An Additional Pet You'd Like to Put on Record?

Yes No
Name
Species:

Canine Feline
Breed
Color
Birthdate

Month Day Year
Date
Sex

Male, intact Male, neutered Female, intact Female, spayed Unknown
Is your pet microchipped?

Yes No No, but I'm interested in getting this done. Tell me more!
Do you have health insurance for your pet?

Yes - please let us know which company in the next box. No. No - but I'm interested in learning more!
If you answered yes to the above for your pet - please list your pet's provider.
We utilize Trupanion Express at our office to help expedite claims for those insured with Trupanion. Please let us know if you'd like us to do so!
What will we be seeing your pet for? What concerns do you have about your pet?
Does your pet have any known allergies?
Has your pet ever had a reaction to vaccines or medications?
Is your pet on any medications or supplements?
Is there anything else you'd like to share with us about your pet? (Personality, etc)
Name of Previous Veterinary Hospital/Clinic
Third Pet
Do You Have An Additional Pet You'd Like to Put on Record?

Yes No
Name
Species:

Canine Feline
Breed
Color
Birthdate

Month Day Year
Date
Sex

Male, intact Male, neutered Female, intact Female, spayed Unknown
Is your pet microchipped?

Yes No No, but I'm interested in getting this done. Tell me more!
Do you have health insurance for your pet?

Yes - please let us know which company in the next box. No. No - but I'm interested in learning more!
If you answered yes to the above for your pet - please list your pet's provider.
We utilize Trupanion Express at our office to help expedite claims for those insured with Trupanion. Please let us know if you'd like us to do so!
What will we be seeing your pet for? What concerns do you have about your pet?
Does your pet have any known allergies?
Has your pet ever had a reaction to vaccines or medications?
Is your pet on any medications or supplements?
Is there anything else you'd like to share with us about your pet? (Personality, etc)
Name of Previous Veterinary Hospital/Clinic
Additional Pets
Do You Have An Additional Pet You'd Like to Put on Record?

Yes No
Please let our support team know that you have additional pets to add to your record. We would be glad to do this over the phone or in person during your visit!

If you have previous medical records you can provide us via text at 317-228-0645 or over email at indyvets@indyvets.com that would be fantastic.

Thank you. 🐾
AUTHORIZATION
Please note that your privacy is important to us. All information received in all forms and through other communication is subject to our Patient Privacy Policy.

We would be more than happy to give you a detailed treatment plan prior to your pet being seen. Please let us know.

I hereby authorize the Doctors and staff of Michigan Road Animal Hospital at 96th Street to provide medical service to my pet(s) and I assume full financial responsibility, understanding that services are to be paid for at the time of requested care. I also understand that a deposit may be required for some surgical services and/or treatments. Any fees associated with an overdue account: late fees, collections agencies costs, attorney fees, and court costs are my responsibility. The charge for a returned check is $35.00
Signature of Owner *

Signature of responsible party/owner must be 18 years old. Clear
Payment Method today:

Cash Check - we will need to see your Drivers License. Care Credit Scratchpay Credit Card (Visa, Mastercard, Discover or Amex)
Payment Method today:
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Welcome to Michigan Road Animal Hospital at 96th Street!

PET INFORMATION:

Second Pet

Third Pet

Additional Pets

AUTHORIZATION