CLIENT INFORMATION
Please Check One:
New Client
Owner’s Contact:
Last
Address:
Street
Current Client w/ New Pet
First
Updated Information
MI
City
State
Zip
Primary Telephone:
Home
Cell
Work
Secondary Telephone:
Home
Cell
Work
Driver’s License #:
Email address:
How did you find out about our practice?
Is this pet co-owned?
Yes
Co-owner’s Contact:
No
Last
First
MI
Primary Telephone:
Home
Cell
Work
Secondary Telephone:
Home
Cell
Work
Please list any additional owners or authorized agents on the next page.
PET INFORMATION
Pet’s name:
Species:
Birth Date or Approx. Age:
Breed:
Sex:
Color(s):
Is your pet spayed or neutered?
Yes
No
Special Identification (tattoo, microchip, etc.)
Date of last DHPP or FVR/CP:
This vaccine expires on
Date of last Rabies vaccination:
This vaccine expires on
Any long-term problems?
Current Medications (including heartworm and flea and tick preventive):
Any allergies or drug reactions?
Reason for today’s visit:
I hereby authorize the veterinarian to examine, prescribe for, and treat, the above described pet. I assume
responsibility for all charges incurred in the care of this animal. I understand that payment is due when services
are rendered and that a deposit may be required for treatment. I also understand that if I do not pay this account, as
agreed, that past due accounts are subject to costs of collection, including court and attorney’s fees.
I am the owner or authorized agent of the owner of the pet presented for care.
Signature of Owner or Agent:
Date:
PATIENT RECORD OF DISCLOSURE
You may release detailed medical information about the above described pet to the following individuals or
organizations:
1. Name:
Relationship:
This person has my permission to make medical decisions for the above pet.
Please initial: Yes
No
2. Name:
Relationship:
This person has my permission to make medical decisions for the above pet.
Please initial: Yes
No
3. Name:
Relationship:
This person has my permission to make medical decisions for the above pet.
Please initial: Yes
No
4. Name:
Relationship:
This person has my permission to make medical decisions for the above pet.
Please initial: Yes
No
5. Name:
Relationship:
This person has my permission to make medical decisions for the above pet.
Please initial: Yes
No
Signature of Owner or Agent:
Date:
IMAGE RELEASE
I irrevocably consent to the use of any images of my pet, taken by Parkview Animal Hospital, in any and all
marketing materials. Please initial: Yes
Signature of Owner or Agent:
No
Date: