"*" indicates required fields Owner’s InformationName* First Last Owner's Date of Birth MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone #*Is it cell? Yes Email* Co-Owner's Name* Phone Number*Please Note: A Co-Owner has permission to make medical and financial decisions.How did you find out about our practice?* Google / Internet Search Social Media Clinic Location / Signage Personal Referral Other Personal Referral: Someone we should thank?* Other:* What Social Media Platforms do you use?* Facebook Instagram Tik Tok Twitter Snapchat Pinterest I DONOT use any platforms Pet’s InformationPet’s Name* Pet’s Name at the Time of Adoption* (applies to pets adopted from Woof Gang Rescue)Species*CatDogSex*MaleFemaleIf Male*NeuteredNot NeuteredIf Female*SpayedNot SpayedBreed* Color/Markings* Date of Birth / Age* Microchip Not microchipped Other Medical InformationPrevious Veterinary Practice (if any)Do we have your permission to collect records?* Yes No Is your pet on any medication or supplements? Please list:*What type of food does your pet eat? Please List Brand & Quantity*Does your pet have any allergies or drug reactions? Please List:*Are there any current or past medical conditions we should be aware of?* Yes No If yes, please explain:*Are there any other pets in the home?* Yes No If yes, please list:*Do you have another pet you would like to register with our practice today?* Yes No 2nd PetPet’s Name* Pet’s Name at the Time of Adoption* (applies to pets adopted from Woof Gang Rescue)Species*CatDogSex*MaleNeutered MaleFemaleSpayed FemaleBreed* Color/Markings* Date of Birth / Age* Microchip Not microchipped Other Medical InformationPrevious Veterinary Practice (if any)Do we have your permission to collect records?* Yes No Is your pet on any medication or supplements? Please list:*What type of food does your pet eat? Please List*What type of food does your pet eat? Please List*Are there any current or past medical conditions we should be aware of?* Yes No If yes, please explain:Are there any other pets in the home?* Yes No If yes, please list:*Photo Consent:We love social media! Do we have your permission to share your pet(s)’ image/video/story on social media, our website & other forms of related media? Your name and personal information will never be shared* YES! You have my permission No, I do not consent Pet Health Savings PlanSay Goodbye to full price with our In-House Savings Plan! Not only will you save 20% on every invoice at every visit, your pet will also receive a FREE Rabies vaccine! YES! Tell me more. I’d like more information on your Pet Health Savings Plan No Thank You. I am not interested in learning more about the plan at this time. Treatment ConsentUpon signing this agreement, I certify I am the Owner/Authorized Agent of the above pet(s) and have authorization to consent to treatment if and when needed. I authorize the American Veterinary Hospital to examine, prescribe for and/or treat the above pet(s).* I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed. *Furthermore I understand an estimate may vary and is not an exact total. I recognize that financial concerns should be discussed PRIOR to exams & treatment.* I recognize that financial concerns should be discussed PRIOR to exams & treatment. * I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed.* I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed. * I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered.* I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered. * Agent’s Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
