Thank you for giving us the opportunity to care for your pet(s). In order to maintain accurate records, we ask that you complete all of the following information.
Your Driver's License #: Enter Driver's License Number*
ALTERNATE EMERGENCY CONTACT:Name: Name of emergency contact person Relation: How is this person related? Phone: Emergency contact's phone number.
Your Employer: Enter employer name* Work Phone: Enter work phone*Spouse's Employer: Spouse emploer Spouse's Work Phone: Spouse work phone
I am aware that South Rhea Animal Hospital requires payment at the time of service. It is not our policy to extend credit. If payment is not made and the account is turned over to our collection agency, I agree to pay a 35% collection fee and reasonable attorney’s fees. Please indicate choice of payment: Initial for cash payment Cash Initial for credit payment Credit Initial for Credit / Debit payment Credit / Debit
Personal recommendation. Whom may we thank? Name of person who recommended us.
I understand South Rhea Animal Hospital is not a 24-hour emergency facility, therefore, referrals to local emergency centers may be recommended if overnight or intensive care is needed.
PET'S NAME:Pet 1: Pet 1 namePet 2: Pet 2 name Pet 3: Pet 3 name SPECIES:Pet 1: Pet 1 species Pet 2: Pet 2 species Pet 3: Pet 3 species BREED:Pet 1: Pet 1 breed Pet 2: Pet 2 breed Pet 3: Pet 3 breed DATE OF BIRTH:Pet 1: Pet 1 DOB Pet 2: Pet 2 DOB Pet 3: Pet 3 DOB COLOR: Pet 1: Pet 1 color Pet 2: Pet 2 color Pet 3: Pet 3 color SEX:Pet 1: Please Select Male Female Pet 2: Please Select Male Female Pet 3: Please Select Male Female SPAYED OR NEUTERED:Pet 1: Please Select Pet 1 Spayed Pet 1 Neutered Pet 2: Please Select Pet 2 Spayed Pet 2 Neutered Pet 3: Please Select Pet 3 Spayed Pet 3 Neutered WEIGHT:Pet 1: Pet 1 weight Pet 2: Pet 2 weight Pet 3: Pet 3 weight PREVIOUS VACCINE REACTION?:Pet 1: Please Select Pet 1 YES Pet 1 NO Pet 2: Please Select Pet 2 YES Pet 2 NO Pet 3: Please Select Pet 3 YES Pet 3 NO DATE OF LAST RABIES VACCINATION:Pet 1: Pet 1 last rabies vaccine date Pet 2: Pet 2 last rabies vaccine date Pet 3: Pet 3 last rabies vaccine date DATE OF LAST DHPP (dogs) or FVRCP (cats):Pet 1: Pet 1 last DHPP / FVRCP date Pet 2:Pet 2 last DHPP / FVRCP date Pet 3:Pet 3 last DHPP / FVRCP date DATE OF LAST KENNEL COUGH VACCINE:Pet 1:Pet 1 last kennel cough vaccine date Pet 2:Pet 2 last kennel cough vaccine date Pet 3:Pet 3 last kennel cough vaccine date DATE AND TYPE OF ANY OTHER KNOWN VACCINES? (FeLV, Leptospirosis, Canine influenza, etc.): Pet 1:Pet 1 other vaccine(s) Pet 2:Pet 2 other vaccine(s) Pet 3:Pet 3 other vaccine(s) CURRENT ILLNESS OR KNOWN CHRONIC CONDITION(S)?: Pet 1: Pet 1 illness / condition Pet 2: Pet 2 illness / condition Pet 3: Pet 3 illness / condition PREVIOUS ILLNESS OR SURGERIES?:Pet 1: Pet 1 illness / surgeries Pet 2: Pet 2 illness / surgeries Pet 3: Pet 3 illness / surgeries CURRENT MEDICATIONS: Pet 1:Pet 1 medications Pet 2:Pet 2 medications Pet 3:Pet 3 medications Initial I give South Rhea Animal Hospital permission to call or email to obtain records for my pet(s) from previous clinics.Initial I give South Rhea Animal Hospital permission to send medical records for my pet(s) to another Vet clinic that may request them.
VACCINATION POLICYSouth Rhea Animal Hospital highly recommends core and required vaccines to protect your pet from deadly diseases common in our area. Certain vaccinations are annual and others are every 2-3 years. These vaccinations will be tailored for each pet and their needs. Please discuss this with your Veterinarian which of these vaccinations is appropriate for your pet. Initial* I understand vaccine reactions can occur, but are rare. The benefits of vaccination outweigh the risks in the majority of pets and most reactions are minor such as facial swelling and hives. These reactions should be reported in order to limit reactions in the future. I understand South Rhea Animal Hospital provides only safe and effective vaccinations that are species-specific and stored appropriately. I also understand that qualified Veterinarians give appropriate “doses” of vaccines as recommended by the manufacturer. Initial* I understand that rabies vaccination is required by State law for all pets and must be kept current. I also understand that Tennessee State law requires a 1-year Rabies booster before starting a three-year protocol. I will provide Rabies vaccination proof and if I cannot provide proof, South Rhea Animal Hospital will require a Rabies vaccination at my pet’s visit unless my pet has an illness, disease, or other special circumstance that would potentially make vaccinating risky. This protects South Rhea Animal Hospital's employees, myself, and the public from a fatal disease that can be carried by bats, skunks, foxes, raccoons, and coyotes. Please Select I consent I DO NOT consent * to the Veterinarians at South Rhea Animal Hospital to vaccinate my pet(s) and accept the potential risk of a vaccine reaction.