New Client Intake Form – Douglas Animal Hospital

Owner Information

Name

First Last

Phone

Alternative Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Emergency Contact Name

First Last

Emergency Contact Phone

Pet Information

Name

Age/DOB

Breed

Past Veterinary Clinic (if applicable)

May we contact them to obtain records?

Any prior surgeries

Allergies

Chronic Health Problems

Origin of Pet

For dispensed medications, my preferred method of administration is

We greatly appreciate the opportunity to care for your pet! To help provide the highest standard in care while maintaining the most reasonable prices, we require that all professional fees be paid at the time of service. Douglas Animal Hospital accepts cash, personal checks, credit cards (Visa, Mastercard, American Express & Discover) as well as CareCredit.

Consent

I grant Douglas Animal Hospital, it’s representatives, and employees the right to take photographs of me and/or my pet(s) and to copyright, use, and publish the same in print and/or electronically. I agree that Douglas Animal Hospital may use such photographs of my pet(s) with or without my name and for any lawful purpose, including, for example, publicity, illustration, advertising, and Web content.

Consent

I authorize the staff at Douglas Animal Hospital to provide treatment to my pet(s).