* = Required

Patient/Client Form

Client Information

Home Mailing Address:

How did you hear of our hospital?  Yellow Pages Sign Newspaper Other

Pet Information

Micro-chipped?  Yes No
Has your pet received veterinary care at another practice in the past 2 yrs?  Yes No
 Male Female
Has your pet been neutered or spayed?  Yes No

Payment

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. The signature below indicates that you assume financial responsibility for all services rendered. We will gladly prepare a written estimate if you desire. Please note there is a service charge for any cheques returned.

To prevent the spread of infectious diseases and parasites, all hospitalized patients must be current on all vaccines and free from internal and external parasites. Upon admission, the signature below authorizes this level of standard preventive care (vaccines / parasite control) with appropriate charges.