WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
HOW DID YOU HEAR ABOUT AVC?
SECONDARY ACCOUNT HOLDERS NAME (if applicable)
PRIMARY PHONE NUMBER
WOULD YOU LIKE TO RECEIVE SMS (TEXT) MESSAGES FOR YOUR PETS UPCOMING APPOINTMENT REMINDERS AND IMPORTANT HOSPITAL ALERTS IE: A CLOSURE DUE TO WEATHER?
SECONDARY PHONE NUMBER (if applicable)
Street Address Line 2
State / Province
Postal / Zip Code
PRIMARY EMAIL ADDRESS ( if you do not have email, please put NA@NA.com )
SECONDARY EMAIL ADDRESS (if applicable)
EMERGENCY CONTACT NAME AND PHONE NUMBER
WILL AVC BE YOUR PRIMARY VETERINARIAN?
No, I have a regular Veterinarian but they are unable to fit me in
No, I was referred by my veterinarian for a procedure or special treatment
No, I am here for a second opinion
I am not unsure at this time. I am considering switching Vets, and will let you know if I decide to use AVC for Primary Care
If you have a primary care Veterinary Clinic, please list the name of the clinic here so we can make sure they receive all medical records after any medical appointment at AVC
PET HEALTH HISTORY
NAME OF PET
BIRTHDATE OR AGE
DOES YOUR PET HAVE ANY BEHAVIORAL OR MEDICAL ISSUES WE NEED TO MADE AWARE OF?
IS YOUR PET CURRENTLY ON ANY PRESCRIPTION MEDICATIONS?
IS YOUR PET UP TO DATE ON HIS/HER RABIES VACCINE?
I AM NOT SURE
CURRENT OR PREVIOUS VETERINARY CLINIC
REASON FOR VISIT? (We do recommend that if your pet is not feeling well, to call AVC and speak with a staff member so we can try and schedule your pet an exam with a Dr. as soon as possible)
FOR ADDITIONAL PETS TO BE ADDED: LIST NAME, SPECIES, BREED, COLOR, AGE AND LIST ANY BEHAVIORAL/MEDICAL ISSUES.
WE SOMETIMES USE HIGH VALUE TREATS SO THAT WE CAN MAKE YOUR PETS EXPERIENCE WITH US AS STRESS FREE AS POSSIBLE. PLEASE CHECK ALL THAT APPLY:
IT IS OK TO GIVE MY PET CHEESE
IT IS OK TO GIVE MY PET PEANUT BUTTER
YOU CAN GIVE MY PET "ANIMAL" TREATS ONLY
YOU CAN GIVE MY PET ANYTHING!
I WILL SUPPLY THE TREATS I WOULD LIKE YOU TO USE FOR MY PET
PLEASE DO NOT GIVE MY PET ANY TREATS AND NOTIFY ME IF HE/SHE IS HAVING A HARD TIME AT THEIR APPOINTMENT.
ANY ADDITIONAL INFORMATION THAT WE SHOULD KNOW ABOUT YOUR PET(S) OR HOUSEHOLD
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 ACCOUNT. I UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME SERVICES ARE RENDERED AND AVC DOES NOT OFFER PAYMENT PLANS OR BILLING. (AVC ACCEPTS: VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, CARE CREDIT AND SCRATCHPAY). I HAVE THE RIGHT TO REQUEST AN ESTIMATE PRIOR TO COMING IN FOR MY PETS REGULAR ANNUAL WELLNESS CARE/VACCINES APPOINTMENT. I HAVE THE RIGHT IF MY PET IS SICK TO REQUEST AN ESTIMATE AFTER MY PETS EXAM BEFORE ANY TREATMENT IS PERFORMED. I ALSO UNDERSTAND THAT A DEPOSIT WILL BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION DURING ADMIT.
DATE OF SIGNATURE
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform