New Client/ Patient Information
Thank you for choosing American Heritage Animal Hospital to care for your pet(s). Please take a few moments to fill out the following information so that we can better serve you and care for your pet(s).
Client Name
First Name
Last Name
Spouse/ Other Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email- We send vaccination reminders via email unless you do not have an email address. We do not sell or share your email with any third parties- it is used exclusively for reminders.
example@example.com
Spouse/Other Mobile Number
Please enter a valid phone number.
Spouse/Other Work Number
Please enter a valid phone number.
Spouse/Other Email
example@example.com
Employer's Name
Spouse/Other Employer's Name
In case of an emergency please call:
Emergency Contact Number
Please enter a valid phone number.
Previous Veterinary Care
Name of Previous/Current Veterinarian
Phone Number
Please enter a valid phone number.
Upload Medical History and Vacination Records
Browse Files
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Patient Information
Patient's Name (1)
Species
Please Select
Canine
Feline
Breed
Color
Age/ Date of Birth
Sex
Please Select
Female Spayed
Female
Neutered Male
Intact Male
Diet- Name of Pet Food
Daily Medications/ Supplements
Heartworm Prevention
Please Select
Proheart 6 or 12
Simparica Trio
Heartgard Plus
Other
Not on prevention
Flea Prevention
Please Select
Nexgard
Simparica/Simparica Trio
Frontline/Frontline Plus
Advantage/Advantix
Other
Not on flea prevention
How many hours a day does your pet spend outside?
Please list any prior illness/surgery.
Patient's Name (2)
Species
Please Select
Canine
Feline
Breed
Color
Age/ Date of Birth
Sex
Please Select
Female Spayed
Female
Neutered Male
Intact Male
Diet- Name of Pet Food
Daily Medications/ Supplements
Heartworm Prevention
Please Select
Proheart 6 or 12
Simparica Trio
Heartgard Plus
Other
Not on prevention
Flea Prevention
Please Select
Nexgard
Simparica/Simparica Trio
Frontline/Frontline Plus
Advantage/Advantix
Other
Not on flea prevention
How many hours a day does your pet spend outside?
Please list any prior illness/surgery.
Patient's Name (3)
Species
Please Select
Canine
Feline
Breed
Color
Age/ Date of Birth
Sex
Please Select
Female Spayed
Female
Neutered Male
Intact Male
Diet- Name of Pet Food
Daily Medications/ Supplements
Heartworm Prevention
Please Select
Proheart 6 or 12
Simparica Trio
Heartgard Plus
Other
Not on prevention
Flea Prevention
Please Select
Nexgard
Simparica/Simparica Trio
Frontline/Frontline Plus
Advantage/Advantix
Other
Not on flea prevention
How many hours a day does your pet spend outside?
Please list any prior illness/surgery.
Authorization to Give Consent
The following individuals are authorized to sign consent forms and give consent to treatment, surgery, and if requested/needed, euthanasia of the pet(s) on my account at American Heritage Animal Hospital. All consent forms are considered legal documents, and these individuals must be 18 (eighteen) years or older at the time they are signing the consent form. If at any time you wish to add or delete an individual from this list, please notify American Heritage Animal Hospital.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
How did you hear about us?
Please Select
Referral
Yellow Pages
Drive By
PawPrints
OurTown
IInternet: snellvillevet.com
LocalVets
Google Search
Other
We GREATLY appreciate referrals and like those that refer to us. Whom can we thank for the referral?
All hospitalized and boarding animals are required to be current on vaccinations. State law required that all dogs and cats be current on rabies vaccinations. Vaccinations can be updated at the time of your appointment. Only vaccines given by a licensed veterinarian will be accepted- breeder and home given vaccines are not accepted for hospitalized and boarding patients. Payment is due at the time services are rendered. We accept cash, local checks, debit cards, Mastercard, Visa, and Discover. Written estimates will gladly be provided at the time. Please ask the veterinarian or technician if you would like an estimate. There will be a service charge for any returned checks. All unpaid balances are subject to finance charge of 1.5% per month from the date of invoice if not paid on time. If the amount due to American Heritage Animal Hospital must be collected through an attorney or collection agency, client agrees to pay 100% of the attorney and/or collection related fees. If the client neglects to pick up pet(s) within 5 (five) days of scheduled discharge date and have not notified the hospital within those 5 (five) days, the hospital may assume that the pet(s) have been abandoned and the hospital may dispose the pet in the manner they deem best and/or necessary.
I agree to the above statement and authorize any doctor employed by American Heritage Animal Hospital to prescribe for and treat my pet(s).
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