Client Information Form

Employer:

Additional Contact & Relation; If pet owner is unavailable:

Name:
Phone Number:

Have you ever been here before?*

Yes

Has this pet been here before?*

Yes

Patient Name*

Type of Animal*

Breed*

Date of Birth*

Sex*

Male

Male Neutered

Female

Female Spayed

Unknown

Diet*

Diet or brand fed:
How often fed:
When last ate:

Primary Veterinarian/Hospital/Clinic*

Please describe the current problem for which your pet is here*

Please check any symptoms or problems that you have noticed about your pet:

Code Status*

CPR

DNR

Current medications (including heartworm prevention, flea control, special diet, etc.)*

Any known allergies or drug sensitivities? If yes, please describe*

How did you hear about us?*

My Vet

Yellow Pages

Internet

Hospital Sign

Other

Will you allow images of your pet on our website/social media?*

Yes

Our doctors use AI software to complete their medical records, so your visit today will be audio recorded. Do you consent to audio recording to aid in patient medical record?*

Yes

WE DO NOT ACCEPT CHECKS
Read the following carefully and sign: Answer all of the below fields completely. Payment is required when service is rendered. Deposit required on all hospitalized animals & surgical procedures.

Method of Payment*

Cash

Care Credit/Scratch Pay

Debit/Credit

Trupanion

I hereby authorize Allied Veterinary Emergency Hospital, its representatives, agent or employees to perform the surgery and/or other necessary services on the above described animal. I further certify that I have ordered, or have been authorized by the owner to order the named services for the above described animal. In any event, I accept full financial responsibility for the payment of services ordered and rendered. I understand that any animal not called for within 3 days of the date that the hospital shall designate for its release shall be considered abandoned by me, and shall be disposed of at the discretion of the hospital. My financial responsibility shall not in any way be altered by such disposal and my indebtedness shall include all charges made against such animal up to and including the date of, and charges for, disposal of same. Should it become necessary to collect this account through an attorney, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees.

Authorization*

Owner/Agent Signature:
Date:

Client Information Form

Employer:

Additional Contact & Relation; If pet owner is unavailable:

Have you ever been here before?*

Has this pet been here before?*

Patient Name*

Type of Animal*

Breed*

Date of Birth*

Sex*

Diet*

Primary Veterinarian/Hospital/Clinic*

Please describe the current problem for which your pet is here*

Please check any symptoms or problems that you have noticed about your pet:

Code Status*

Current medications (including heartworm prevention, flea control, special diet, etc.)*

Any known allergies or drug sensitivities? If yes, please describe*

How did you hear about us?*

Will you allow images of your pet on our website/social media?*

Our doctors use AI software to complete their medical records, so your visit today will be audio recorded. Do you consent to audio recording to aid in patient medical record?*

WE DO NOT ACCEPT CHECKS Read the following carefully and sign: Answer all of the below fields completely. Payment is required when service is rendered. Deposit required on all hospitalized animals & surgical procedures.

Method of Payment*

Authorization*

WE DO NOT ACCEPT CHECKS
Read the following carefully and sign: Answer all of the below fields completely. Payment is required when service is rendered. Deposit required on all hospitalized animals & surgical procedures.