BAY ANIMAL HOSPITAL CLIENT INFORMATION FORM

Owner Name:*

First NameLast Name

Spouse/Other:

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone:*

Please enter a valid phone number.

Secondary Phone:

Please enter a valid phone number.

Email Address:*

example@example.com

Driver License Number:

State:*

Date of Birth:*

Date

Employer:

Additional people authorized to request treatment:*

How did you hear about us?*

Previous Animal Hospital:*

Rabies Vaccine: We require your pet to have a current rabies vaccine. If you cannot provide proof of the vaccine, it will be given at the time of your pets visit.

Prescription Policy: We offer Flea, Tick, Heartworm and Food prescriptions through our online pharmacy (Vets First Choice) with a 20% off coupon code. If you would like to use a different pharmacy, please let us know during your visit and we will give you a written prescription that you can take to the pharmacy of your choice. Depending on the reason your pet is on medication, we may require your pet to be seen every 3-6 months for bloodwork and/or an exam, or the refill will be denied.

A treatment plan will be prepared for you when diagnostics are recommended. By signing below, you are acknowledging our prescription policy, giving us permission to treat your pet, and you assume responsibility for all charges incurred in the care of your pet being seen at Bay Animal Hospital. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
There will be a $50.00 service charge for any check returned unpaid.

Photography Authorization: Do you authorize us to use any photos of you and/or your pet(s) taken during your visit on our website or social media?*

YESNO

Date*

Date

Signature of Responsible Agent for Pet(s):*