CLIENT INFORMATION FORM PET INFORMATION
CLIENT INFORMATION FORM 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 help us provide the best care possible, please take the time to fill out the following form completely. Owner:_______________________________
Phone (home):_________________________
Address:______________________________
(work):__________________________
City/State:_____________________________
(cell):__________________________
Place of Employment:____________________
Drivers License #_______________________
Co-Owner/Spouse:______________________
E-Mail Address:_________________________
How did you hear about us?
□Verizon YP □Pacific Bell YP □Referral/Friend_____________ □Other____________ PET INFORMATION
Species:
□Cat
□Dog
□Rabbit
Pet's Name____________________________ Color:________________ Usual Personality:
Sex (circle one): Female
□Other:__________________________________ Breed:________________________________ Spayed
Male
Neutered
DOB/Age:__________
□Friendly/Outgoing □Friendly/Shy □Shy/Possibly Aggressive □Aggressive in New Environment
Previous Vet:___________________________Current Allergies/Medications:___________________ Permission to contact your previous veterinarian to request copies of your pet's medical records?
□ Yes
□No
I hereby authorize the veterinarians to examine, prescribe, or treat the above-described pet. I, the owner/agent and coowner, both assume all financial responsibility for my pet. I also understand that payment is due at the time services are rendered and that a deposit may be required for services. If a deposit is required an estimate will be provided. All fees incurred after the initial deposit will be due in full at the time of discharge. All fees not paid in full will be subject to billing charges, finance charges and collections fees. The presence of personnel is not provided after St. Francis Pet Clinic's posted business hours.
Signature of Owner/Agent:____________________________________
Date:___________________
Signature of Co-Owner:_______________________________________
Date:___________________
Phone (home):_________________________
Address:______________________________
(work):__________________________
City/State:_____________________________
(cell):__________________________
Place of Employment:____________________
Drivers License #_______________________
Co-Owner/Spouse:______________________
E-Mail Address:_________________________
How did you hear about us?
□Verizon YP □Pacific Bell YP □Referral/Friend_____________ □Other____________ PET INFORMATION
Species:
□Cat
□Dog
□Rabbit
Pet's Name____________________________ Color:________________ Usual Personality:
Sex (circle one): Female
□Other:__________________________________ Breed:________________________________ Spayed
Male
Neutered
DOB/Age:__________
□Friendly/Outgoing □Friendly/Shy □Shy/Possibly Aggressive □Aggressive in New Environment
Previous Vet:___________________________Current Allergies/Medications:___________________ Permission to contact your previous veterinarian to request copies of your pet's medical records?
□ Yes
□No
I hereby authorize the veterinarians to examine, prescribe, or treat the above-described pet. I, the owner/agent and coowner, both assume all financial responsibility for my pet. I also understand that payment is due at the time services are rendered and that a deposit may be required for services. If a deposit is required an estimate will be provided. All fees incurred after the initial deposit will be due in full at the time of discharge. All fees not paid in full will be subject to billing charges, finance charges and collections fees. The presence of personnel is not provided after St. Francis Pet Clinic's posted business hours.
Signature of Owner/Agent:____________________________________
Date:___________________
Signature of Co-Owner:_______________________________________
Date:___________________
