Welcome Form

Throughout the patient’s treatment, we maintain open communication with your primary care vet, and upon completion of the treatment your pet will return to their veterinarian for routine care. Please feel free to discuss any part of the MEDICAL PLAN with the staff. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Your pet must be parasite free and up to date on their rabies vaccine upon admission to the hospital. This policy is to prevent unnecessary transmission of parasites to other patients as well as the protection of your pet. If your pet has parasites or needs their rabies vaccine, they will be treated at your expense.

To insure the best care possible, please take the time to fill in this form completely.
Thank you for trusting your best friend(s) to us.

In order to open an account with us you must be 18 years of age and provide us with at least one form of identification to be presented at your first vet visit. Your information will be kept confidential.

Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone

Please enter a valid phone number.Format: (000) 000-0000.

Phone type

Email

Employers Name

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Is there a Co-owner or second authorized individual you would like added to the account?

Co-Owner Name

First NameLast Name

Co-Owner Phone

Please enter a valid phone number.Format: (000) 000-0000.

Is the home address for the Co-Owner/Agent the same as the owner's listed above

Home Address of Co-Owner

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Co-Owner Employer

Co-Owner Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Co-Owner Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Method of Payment:

Pet's Name

Age/Birthdate

type of Pet:

Other

Sex/Status

Breed

Color/Markings

Relevant History

Please list any relevant surgeries, and how they were performed.

is your pet Current on Rabies?

Rabies Expiration Date

Current Primary Vet

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Has your pet been seen at any other veterinary facility? (specialists, emergency clinics, referral vets etc)

Please list any additional Veterinary Care, Specialists or Surgical Centers

Clients Acknowledgements

I certify that the information I have provided is accurate to the best of my knowledge. I acknowledge that I must provide a VALID DRIVER'S LICENSE or GOVERNMENT ISSUED ID at my first visit. I understand that I am financially responsible for all services rendered and that payment is due at the time of service. I further acknowledge that I have been informed of the hospital’s policies regarding payment and communication. If my account becomes delinquent, I agree to be responsible for all associated costs of collection, including collection agency fees, attorney fees, and court costs. I agree to abide by these policies as a client of Animal Rehab & Pain Center.

Welcome Form for New Clients

Pet Owner's Information

Pet's Information

Veterinary history