Franklin County Animal Hospital New Client Form

We know your pet's health is very important to you. We would like to thank you for trusting Franklin County Animal Hospital to care for your pet(s). To help us provide the best possible care, please take a few moments to fill out this form completely. Thank You!
OWNER'S NAME*

First NameLast Name
MI
SPOUSE
Primary Phone # (We will call this one first)*
Spouse Phone #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS*
example@example.com
CELL PHONE NUMBER WE CAN TEXT YOU WITH UPDATES REGARDING YOUR PET*
EMERGENCY CONTACT NAME*
EMERGENCY CONTACT PHONE NUMBER*
HOW DID YOU LEARN ABOUT OUR CLINIC?
PET HEALTH HISTORY
NAME OF PET*
Species (Ex: Cat, Dog, Etc)*
Sex (Male/Female)*
Has your pet been spayed or neutered? Yes or No*
BREED*
COLOR*
BIRTHDATE OR ESTIMATED AGE*
PREVIOUS VETERINARY HOSPITAL NAME AND NUMBER
PREVIOUS VACCINE HISTORY
REASON FOR VISIT*
Please list any known allergies, medical conditions and any medication your pet is currently on:*
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. I ALSO UNDERSTAND AND ACCEPT RESPONSIBILITY FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
SIGNATURE*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
Method of payments accepted:

American Express/ Visa / Mastercard / Discover

Care Credit / ScratchPay

Cash / Check
Should be Empty:

PET HEALTH HISTORY

AUTHORIZATION