Patient and Client Information Sheet

Call Us Today! (305) 945-1223

Thank you for giving our clinic the opportunity to care for your pet. So that we may better meet your needs, please completely fill out the information sheet.

Client Information

Your First Name:

Your Last Name:

Home Address:

Home Phone:

Work Phone:

Cell Phone:

Place Of Employment:

Work Address:

Email:

In Case Of Emergency, Name Of Authorized Person To Act On Your Behalf:

Patient Information

Pets cannot talk for themselves; therefore, good client/doctor communication is essential. Feel free to ask us any questions. Please do not underestimate the possible importance of any odd behavior or occurrences to your pet’s health, ask the doctor! We welcome your enthusiasm in caring for your pet. Thank you.

Pet's Name:

Species:

Breed (Doberman/Siamese):

Description(color/markings):

Sex:

Age(Months/Years):

Altered/Spayed?

Microchip number:

Are you a Pet Assure participant?

Do you have Pet Health Insurance? Which company?

If not, would you like information and a free 30 day trial?

Have your pets been to a vet before?

Date of last visit

Name of Clinic/Doctor

Was there a reason for changing?

How did you become aware of us?

Referred by another veterinarian (which clinic or doctor)

Personal recommendation (Whom may we thank?)

Other:

Financial Policy

Unlike human hospitals, the facilities we provide are entirely due to private enterprise and the investment of our veterinarians. Our goal is to provide pet owners with the most advanced medical care available. The fee structure for services rendered is based on the financial demands of maintaining a professional staff and modern equipment. We have no desire to extend anyone beyond their means or intentions. Communication regarding finances is extremely important. In-house financing is available with a valid checking account and debit card. Upon request, a treatment plan and the fees associated can be presented before any treatment or surgery is performed. If your pet’s condition changes, the treatment plan may need to be revised.

All fees are payable at the time of the visit.

Please Indicate Your Choice Of Payment Method:

Submission of checks for payment grants the authorization to convert the check to an electronic transaction. In-house financing requires a $35.00 application fee with approval. Sorry, we do not carry open accounts and hope these alternatives are convenient for you.

To prevent the spread of infectious diseases and parasites, hospitalized or boarded animals must be current on all vaccines and be free of internal and external parasites.

Thank you for bringing your pet to our clinic. We hope you are pleased with our services and facilities, and would appreciate your letting us know how we might improve them.

Please prove you are human by selecting the Heart.

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