Billings Animal Family Hospital - PATIENT/CLIENT INFORMATION

1
* This field is required.
Your Name/Title
Spouse/Partner
Address
City
State
Zip
2
We use e-mail for pet portal access, newsletters, reminders, client education and other notifications. We NEVER sell email addresses.
Home Phone
Cell phone
Work Phone
Your Email Address
Spouse/Other Email
3
Spouse/Partner Cell Phone
Spouse/Partner Work Phone
Your Employer
Spouse/Partner Employer
Your Driver’s License Number
State (if you wish to pay by check)
In case of EMERGENCY, please call
@ Telephone
4
Do you prefer email/electronic communications over paper?
Yes
No
Both
5
Would you like to receive text message reminders of appointments?
Yes
No
At which number?
6
At which number?
7
How did you first learn of our hospital?
Hospital Sign
Please Select
Hospital Sign
Yellow Pages
Ad Friend/Co-worker/Relative
Internet
Other
Referred by
8
Please Describe
9
We would like to thank any individual who referred you.
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At your request we will gladly discuss cost of services and prepare a written treatment plan for procedures.
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
We accept cash, local checks. debit cards, VISA, MasterCard, Discover and American Express
We also offer CARE CREDIT Payment Plans. Please ask if you would like to apply.
I agree to be responsible for authorizing procedures and/or paying for services
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SIGNATURE
Clear
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DATE SIGNED
Date
Year
Month
Day
13
ANIMAL IDENTIFICATION AND MEDICAL INFORMATIONPET # 1
Name
Please Select
Please Select
Cat
Dog
Other
Animal Type
Breed
Description/color
Age
Date of Birth
Sex – Spayed/Neutered?
Length of Time Owned
14
How Obtained?
Previous Hospital/Vet
Microchip #
Vaccinations
DHPP
Bordetella
Rabies
FVRCP
15
FELV
Any Other Vaccines?
Groomer
Kennel
Current Medications
Special Diet
Prior Illness/Accidents
Prior Surgery/Dentistry
16
Would you like to add another pet?
Yes
No
17
PET # 2
Name
Please Select
Please Select
Cat
Dog
Other
Animal Type
Breed
Description/color
Age
Date of Birth
Sex – Spayed/Neutered?
Length of Time Owned
18
How Obtained?
Previous Hospital/Vet
Microchip #
Vaccinations
DHPP
Bordetella
Rabies
FVRCP
19
FELV
Any Other Vaccines?
Groomer
Kennel
Current Medications
Special Diet
Prior Illness/Accidents
Prior Surgery/Dentistry
20
Would you like to add another pet?
Yes
No
21
PET # 3
Name
Please Select
Please Select
Cat
Dog
Other
Animal Type
Breed
Description/color
Age
Date of Birth
Sex – Spayed/Neutered?
Length of Time Owned
22
How Obtained?
Previous Hospital/Vet
Microchip #
Vaccinations
DHPP
Bordetella
Rabies
FVRCP
23
FELV
Any Other Vaccines?
Groomer
Kennel
Current Medications
Special Diet
Prior Illness/Accidents
Prior Surgery/Dentistry
24
APPOINTMENT DATE* This field is required.Please provide the date of your scheduled appointment
Date
Year
Month
Day
25
What is the reason for your visit today?
Any other questions/concerns/comments?
Should be Empty: