Custom Form15

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s).

Owner's Name

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First Name:*Required

Last Name:*Required

Street Address:

Address Line 2:

City:

State / Province / Region:

ZIP / Postal Code:

Country:

Day-Time Phone:*Required

Evening Phone:*Required

Mobile Phone:*Required

Email:*Required

 

Co-Owner's Name /Emergency Contact Name & Contact Number

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First Name:

Last Name:

Phone:

How did you find out about our practice?
Clinic LocationPersonal ReferralInternet Search / WebsiteYellow PagesClinic SignNewspaper / Print MediaOther

If other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family:

 

Pet Information

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Pet's Name:*Required

Species:
Dog Cat Rabbit Ferret Bird Reptile

or if other species:

Breed (if known)

Temperament:

Do you plan on leaving your pet at a boarding facility?
 Yes  No

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex:
Neutered Male Spayed Female Male Female Unknown

Date of last vaccines (if known)

What vaccines were given at this time?

Is your pet on any medication or supplements?
YesNo

If Yes, please list the medication or supplements:

What food does your pet eat?
Does your pet receive any human food in addition to their regular diet? If yes, please list the types of food, portion sizes, and how often they are given.

Does your pet have allergies or drug reactions?
YesNo

If Yes, please list the allergies and reactions:

Are there any current or past medical conditions of which we should be aware?
YesNo

If Yes, please comment on the condition(s) and indicate if they are current or past conditions:

Please use the following box to give us any other relevant information about your pet:

 I give permission for my pets photo to be used in the BHVC medical file and on BHVC social formats or digital formats.

 Yes  No

Medical Records 

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May we request your pets records from another clinic?
 Yes  No

Previous Clinic Name:

Previous Clinic Phone Number:

May we release your pet's records to other clinics if requested
Yes  No

I authorize the veterinarian to examine, prescribe and treat the pet listed above. I assume responsibility for all charges and cured in the care of this animal.

Owner signature( Print Name for E-signature):

Date:

** All Fees are due at the time services are rendered**

Thank you for giving us the opportunity to care for your pet!