Title_____Name:______________________________________________________________________ (Last) (First)
Title_____Spouse/other_________________________________________________________________ (Last) (First)
Address:_____________________________________________________________________________ (Street) (City) (State)(Zip Code)
Alternate Cell/Home phone:________________ Cell___________________ Work______________________________
(We need this for you to be able to access your Pet Health Profile)
Employer________________________ Spouse/Other Employer__________________________________Work phone_____________________How did you hear about us? (Please circle) 1.) Web site 2.) Return client 3.) Referring Hospital 4.) Sign or location 5.) Social Media 6.) Other 7.) Personal Referral -whom may we thank? Please include address:__________________________________
Birthdate ____________ or how old_____yrs________mos_______wks
(please circle) Dog or Cat If cat Indoor / Outdoor / Both
Male or Female Spayed / Neutered / Unknown
Microchip name and Number___________________________________________________________
1) Has your pet been to a veterinarian before, if so, how long ago?_______________________________
Reason for changing?_______________________________________________________
2) Are you interested in learning about preventative programs to protect your pet from internal parasites? YES / NO
3) Are you aware of the health benefits of regular pet dental cleaning? YES / NO
4) Are you interested in learning precisely formulated diets that help prevent disease and increase your pet’s health for a happy long life? YES / NO
5) What do you currently feed your pet?__________________________________________________
6) Do you have other pets at home?______________________________________________________
8) Have you ever noticed any behavior problems or concerns with your pet? _____________________
9) Do you have any concerns about your pet’s health that you desire advice on from us?
10) What prior illnesses, surgeries or allergies should we be aware of?___________________________
11) What type of flea/tick control are you using?________________________________________________
12) Please list any medications, vitamins or prescription diet your pet is currently taking/being fed:
13) Are there times you may be in need of boarding and or grooming services from us? YES / NO
Please let a staff member or Doctor know if you would you like an estimate prior to us proceeding beyond the examination.
PAYMENT POLICY: All fees are due at time of service. We accept VISA, MASTERCARD, DISCOVER, CHECK with I.D., and/or CASH. There will be a $30.00 service charge for any check returned “unpaid”. Any balances will be sent to a reputable agency for collection. The person signing below is responsible for such collection fees of an additional 33%-40% as well as any associated attorney fees.
You are subject to a $25 fee for all No-show/missed appointments.
We know you have choices in where you obtain care for your pet. We sincerely appreciate and thank you for the trust you have placed in us. The Doctors and Staff of Aurora Pet Hospital