Client Intake Form

Compassionate Crossings, LLC

compassionate-crossings.com 205-531-0160
Client Intake Form

If unable to complete the following information prior to visit, Dr. Floyd will also have these forms available for you to complete. Completion of this form is required PRIOR to appointment beginning.
Owner/Client Information
Owner Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Preferred Contact Number
Please enter a valid phone number.
Have you ever used our services before?

YesNo
How did you hear about us?

Internet searchReferred to you by a friend/past clientReferred to you by my primary veterinarianSaw you on TVSaw you in the paperSocial media post

Patient Information
Pet's Name*
Species*
Breed
Any aggression exhibited by pet that may necessitate a muzzle during visit?*
Sex
Color
Age
Approximate Weight*
in lbs.
Primary Veterinarian or Clinic*
Primary Veterinarian or Clinic Phone Number*
Please enter a valid phone number.
Please provide a brief summary discussing why your pet is a candidate for euthanasia today:*

Euthanasia Consent Form

QUESTIONS REGARDING ANY OF THE REQUIRED STATEMENTS BELOW CAN BE ADDRESSED BY THE ATTENDING DOCTOR.
I, the undersigned, certify that I am the owner (or an authorized agent for the owner) of the animal described above and I consent to, and order euthanasia to be performed on said animal.
I have read and understand the above statement*

AgreeDisagree
I do hereby give the doctors of Compassionate Crossings of Birmingham, LLC, their
staff, and representatives full and complete authority to euthanize and handle the
aftercare of said animal. Furthermore, I forever release the said doctors of Compassionate Crossings of Birmingham, LLC, their staff, and representatives from all liability for euthanizing and aftercare of said animal.
I have read and understand the above statement*

AgreeDisagree
To the best of my knowledge, said animal has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.
I have read and understand the above statement*

AgreeDisagree
I understand that I assume all financial responsibility for all services rendered. Due to the nature of the services and products offered, all sales are final.
I have read and understand the above statement*

AgreeDisagree
Signature*

Clear
Date*

MonthDayYear
Date

Compassionate Crossings, LLC