Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Permanent I.D. number (social security OR drivers license):
Secondary contact name AND phone number:
How did you hear about us?
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 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 consent to the use of periodic appointment and or service reminders via phone calls, voice mail messages, post cards, and/or emails.
I do not consent
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.
Should be Empty: