Welcome Sheet

Welcome Sheet
Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill in this form completely.

Thank You!!
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Employer*
Driver's License Number
Spouse
Spouse Phone Number

Area CodePhone Number
Emergency contact name and phone number*
Referred By
Media Release: permission to post photos/videos of your pet online for educational purposes?*

YesNo
Medical record Release: permission to send records to other clinics/organizations when requested?*

YesNo
Pet Health History
Pet's Name*
Species*

DogCatHorseOther
Breed*
Color
Age or Date of birth*
Sex*

Female intactFemale spayedMale intactMale neutered
Vaccine History (date and type of last vaccines)
Previous health problems
AUTHORIZATION
I, the undersigned, certify that I am the legal owner or legal agent of the owner and of sufficient age and capacity to authorize care and treatment of the animal being treated and cared for at Sagehills Veterinary Services. I, the undersigned, understand and agree to pay a monthly service charge of 1.5% (18% per annum) on all charges. By signing, I acknowledge that client accounts are not charge accounts. Payment is due at time of service.

Abandoned animals will be adopted or euthanized in accordance with Washington State Law Chapter 16.54 and other state law as amended from time to time.

I hereby certify that the contact information on this record is current and complete and is the appropriate information for the hospital to contact regarding any issues involving the animal to be admitted.
Method of Payment*

CashCheckCredit CardCare CreditScratchpay
Signature*

Clear
Should be Empty:

Welcome Sheet

Pet Health History

AUTHORIZATION