OCAC Client & Patient Information

Client Information
DateTime
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Other

First NameLast Name
Spouse/Other Phone #

Area CodePhone Number
Employer
Work Phone Number

Area CodePhone Number
Other person(s) authorized to order treatment or obtain information (option)
Other person(s) Phone #

Area CodePhone Number
Pet Information
Pet's Name*
Species*
Sex*
Birthday
Age
Breed*
Example: Lab, Poodle, Domestic Shorthair, etc.
Color*
Markings
Any special markings to help identify your pet
Microchipped?*
Heartworm Medication?*
Is your pet currently taking monthly heartworm prevention?
If taking heartworm prevention, what type are they taking?
Current Medications
List any medications your pet is currently taking, vitamins/supplements included
Special Diet*
Is your pet eating a special diet?
If eating a special diet, what are they eating?
Medical History
List any medical history you feel our doctor needs to be aware of.
Pet Insurance Company/Type of Insurance*
If no pet insurance, write "N/A" or "none"
Photo Release: Ohio County Animal Clinic, PLLC may use photos of my pet(s) for advertising, social media, and other purposes. I understand that I will not be compensated in any way for allowing usage of my pet(s) image(s).
Type a question*

Yes, my pet(s) image(s) may be used by Ohio County Animal Clinic, PLLCNo, I prefer that my pet(s) image(s) not be used by Ohio County Animal Clinic, PLLC
Financial Information
FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

We accept cash, check, Visa, Master Card, Discover, & American Express.

Need financing? We accept Care Credit and ScratchPay. Ask a receptionist for more information.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.
By signing below I acknowledge the information provided is accurate to the best of my knowledge and I fully understand the payment policy.
Please sign in the box (it's hard to see)*

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Upload any previous records/history

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Upload a current image of your pet for their medical file

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Client Information

Pet Information

Financial Information