Client/Patient Information

Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

E-mail *

Spouse/Other

First Name Last Name

Phone Number

- Area Code Phone Number

How did you hear about us? (Whom may we thank?

Ex. Friend (Please Specify), Search Engine, Location/Drive By, etc.

Hospital Policies

1. Payment is due at time of service. We accept Cash, Visa, MasterCard, Discover, American Express, CareCredit, Scratch Pay, and personal checks (with a valid Texas driver's license).
2. Written Treatment Plans are available upon request. Treatment Plans are made in good faith and the doctors do their best to stay as close as possible to the provided plan, however unpredictable costs do occasionally occur and will be the responsibility of the client.
3. It is our policy to not release patient medical records/information (other than vaccine history) without the expressed permission of the client.
4. Off label use of medications is common in veterinary medicine. Every effort is made to use veterinary labeled products at recommended guidelines. However, for some cases it is important to use medications or compounded products in an off label fashion as determined by the doctor.

By signing below, I am acknowledging I have read and agree to the above hospital policies and give the doctors and staff of High Point Animal Hospital permission to examine and treat my pet(s).

Signature *

Clear

Now tell us a little about your pet!

Pets Name *

Species *

Dog Cat

Color

Date of Birth or Estimated Age

Sex

Male Neutered Male Female Spayed Female

Does you pet take a monthly heartworm prevention?

Yes No Unknown

If yes, which brand?

Does you pet take a monthly flea prevention?

Yes No Unknown

If yes, which brand?

Has your pet ever had a reaction for vaccines or medications?

Yes No Unknown

If yes, please specify.

Does your pet have any behavior issues?

Yes No Unknown

If yes, please specify.

Previous Veterinarian

Please verify you're not a robot. *