Thank you for giving us the opportunity to care for your pet. Please help us meet your needs
better by taking a moment to share some importnat information we will need as we support
your pet's needs today and in the future. You can assist us to expedite your check in by
printing this form, filling out all the spaces and bringing it with you to your appointment.
Thank you for your cooperation in letting us assist you.
PRIMARY OWNER
NAME:
LAST____________________FIRST___________________________
MAILING ADDRESS:
STREET ADDRESS___________________________________________________________
CITY__________________________________STATE____________ZIP_______________
CONTACT INFORMATION:
HOME_______________________CELL__________________________WORK___________________
EMAIL ADDRESS_____________________________________________________________________
WHICH IS THE BEST WAY TO CONTACT DURING THE DAY? _________________________________
WHICH IS THE BEST WAY TO CONTACT AFTER BUSINESS HOURS?____________________________
EMPLOYER________________________________________________OCCUPATION_______________
SPOUSE/CO-OWNER
NAME: LAST___________________________FIRST__________________________________________
MAILING ADDRESS: (IF DIFFERENT THAN ABOVE)
STREET ADDRESS_____________________________________________________________________
CITY__________________________________STATE______________ZIP _____________
CONTACT INFORMATION:
HOME________________________CELL_________________________WORK_____________________
EMAIL ADDRESS______________________________________________________________________
WHICH IS THE BEST WAY TO CONTACT DURING THE DAY?___________________________________
WHICH IS THE BEST WAY TO CONTACT AFTER BUSINESS HOURS?_____________________________
EMPLOYER_________________________________________OCCUPATION_______________________
RELATIONSHIP TO PRIMARY OWNER?_____________________________________________________
HOW DID YOU HERE ABOUT US?
Yellow Pages Drove by Hospital Personal Referral
Who may we thank?________________________________________
PET INFORMATION
:
| Name |
|
Species? |
Dog |
Cat |
| Birth Date |
|
Sex? |
Male |
Female |
| Breed |
|
Neutered? |
Yes |
No |
| Color |
|
Spayed? |
Yes |
No |
| Marking(s) |
|
Vaccinated? |
Yes |
No |
If your pet(s) travel (or have traveled) out of the area, where? ______________________________
EMERGENCY TREATMENT
In the event of an emergency, do you authorize treatment of your pet(s) if every attempt
made to contact you was unsuccessful? YES NO INITIAL ___________
I, the undersigned, and owner or authorized agent of the above mentioned pets, do hereby authorize
Adams Animal Hospital to perform such examinations, diagnostic tests and treatments as necessary.
I further agree to be financially responsible for all costs for such procedures and treatments. I understand
that full payment is due at the time services are rendered. I understand that abandonment of animals
does not relieve me of this financial obligation. Failure to pay bills on time may result in billing, finance
charges and/or costs of any collection fee incurred.
SIGNATURE___________________________________________________DATE______________________
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