Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Permanent I.D. number (social security OR drivers license):
*
Secondary contact name AND phone number:
*
How did you hear about us?
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Pets name
*
Species?
*
Please Select
Canine
Feline
Lagomorph
Mustelid
Avian
Marsupial
Reptile
Amphibian
Rodent
Breed?
*
Color/markings?
*
Sex?
*
Please Select
Female
Female, spayed
Male
Male, Neutered
Any major health issues?
On any current medications?
Has this pet been seen by another veterinarian? If so, which one? Please include full hospital name, and number if possible.
*
Why are we needing to see your pet?
I understand that prior to intake, a full explanation of fees and services will be given to me by a staff member in the care of my animal(s). In the event that I cannot be reached but my pet needs treatment, I authorize the doctor to use their medical judgement to best treat my pet.
I understand
I understand that I assume full responsibility for ALL charges incurred in the care of my pet(s). I also understand that these charges must be paid in full at the time of release.
I understand
I consent to the use of periodic appointment and or service reminders via phone calls, voice mail messages, post cards, and/or emails.
I consent
I do not consent
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I understand that Sewell Animal hospital is typically booking out 1-2 weeks for new clients, and that SAH requires a deposit for booking (exam price), and I will be contacted via email or text regarding scheduling.
I understand
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