Sherwood South Animal Hospital - Client & Patient Information Form

Client & Patient Information Form

Welcome, and thank you for giving us the opportunity to care for your pet! To help us better serve you and get to know you, please take a moment to complete the following form.
Today's Date*

MonthDayYear
Date
Reason For Visit*
Primary Care Veterinary Hospital*
To facilitate seamless communication and ensure the best possible care across all providers, please list any other veterinary hospitals involved in your pet’s care
Client Information
Owner's Name*

First NameLast Name
Co-Owner's Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Phone Number*
Please enter a valid phone number.
Co-Owner Phone Number
Please enter a valid phone number.
Owner Email*
example@example.com
Co-Owner Email
example@example.com
Owner Place of Employment
Co-Owner Place of Employment
In case of emergency, is there anyone else we can contact if you are unavailable?Name/Relation/Phone:*
Patient Information
Patient Name*
Species*

CanineFeline
DOB (or approx. age)*
Breed*
Sex*

MaleMale NeuteredFemaleFemale Spayed
Permanent I.D. (tattoo or microchip?)
I.D. #
Has your pet been vaccinated in the last 12 months?*

YesNo
Vaccination History (What, When, Where):*
Is your pet on heartworm prevention?*

YesNo
Is your pet on Flea/Tick Prevention?*

YesNo
Is your pet on any special diets or medications? If so please, list. *
Any previous serious illness or surgeries? If so please, list. *
Any allergies to vaccines or medication? If so please, list. *
Relevant History
My pet lives*

Indoors onlyMainly indoorsHalf Indoor Half OutdoorOutdoors only
Please list the names and types of other animals that you own
Social Media Agreement:

In the course of advertising, public relations or other similar conduct for business purposes, Sherwood South Animal Hospital Emergency & Critical Care Center may utilize media resources.

I grant to Sherwood South Animal Hospital Emergency & Critical Care Center, it representative and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically without compensation.

I also agree that Sherwood South Animal Emergency & Critical Care Center, may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. This would be true of any written statement I have made regarding my pet or my experiences at Sherwood South Animal Hospital Emergency & Critical Care Center.
YES, Sherwood South Animal Hospital Emergency & Critical Care Center may take photos of me and/or my pet.NO, Sherwood South Animal Hospital Emergency & Critical Care Center may not take photos of me and/or my pet.
Referral Policy:

The following policy applies to patient referrals from your primary care veterinarian for treatment at Sherwood South Animal Hospital Emergency & Critical Care Center. Our veterinary team will focus solely on the emergency for which your pet was referred. We are unable to provide any additional care beyond what has been specifically requested by your pet’s primary veterinarian. Assuming responsibility for care that should be provided by the referring veterinarian would be considered a breach of professional ethics.

I hereby acknowledge that Sherwood South Animal Hospital Emergency & Critical Care Center does not bill for services. Payment is expected at the time that services are rendered. We accept cash, major credit cards, Care Credit, & Scratchpay. Estimates can be made available at the owner’s request before services are performed.

To ensure we can provide treatment for your pet, we require a photocopy of the responsible party’s valid driver’s license prior to emergency admission. This is a standard hospital policy, and we are unable to make exceptions.

Payment Agreement:

I hereby acknowledge that Sherwood South Animal Hospital Emergency & Critical Care Center does not bill for services. Payment is expected at the time that services are rendered. We accept cash, major credit cards, Care Credit, & Scratchpay. Estimates can be made available at the owner’s request before services are performed.

To ensure we can provide treatment for your pet, we require a photocopy of the responsible party’s valid driver’s license prior to emergency admission. This is a standard hospital policy, and we are unable to make exceptions.
Signature*

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Client & Patient Information Form

Client Information

Patient Information