Thank you for visiting our hospital. We look forward to getting to know you and your pet. Please help us to provide the best care possible for your pet by taking a moment to fill out this form. Practice NoneEdge Animal Hospital Haines Road Animal Hospital Patient's Name * Client / Owner Information Name * Address * Address Cont'd City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP * Email * Home Phone * Cell Phone * How would you prefer us to contact you? Phone Email text Work Phone * Occupation Employer's Name and Address We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, CASH, AND CARE CREDIT. If you plan to use a credit card or Care Credit, please provide your driver’s license to the receptionist to make a copy. Driver's License # * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Height Spouse / Co-Owner Information Name Cell Phone Work Phone Email Occupation Employer's Name and Address Emergency Contact In case of emergency, who should we contact? Phone Number How did you hear about us? How did you hear about us? - None -FriendInternetTelephone BookDrive By/Saw Our SignOther (Please fill in below) Other Doctor ReferralIf you have been referred to us by another veterinarian, please provide their information below. Doctor's Name Hospital Name State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Phone Please tell us about your pet(s) Name * Type of Pet * - Select -DogCatOther (Please fill in below) Other Breed * Color Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Sex * - Select -MaleFemale Spayed / Neutered? * - Select -YesNo Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Sex - None -MaleFemale Spayed / Neutered? - None -YesNo To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites to enter our hospital for surgery, boarding, drop off or hospitalization. I hereby certify that I am the legal owner of the below-listed pet(s) and accept full financial responsibility for their treatment and care. I authorize the doctors of Haines Road Animal Hospital to provide medical treatment, vaccines, and parasite control for my pet(s). Initials * I authorize Haines Road Animal Hospital to use my pet’s pictures on social media. Initials * I authorize Haines Road Animal Hospital to release my pet’s records to other vets, boarding facilities, etc. Initials * I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet. Signature Signer Name *
