Owner's Information

Name *

First

Last

Phone *

Work Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Co-Owner's Information

Name

First

Last

Phone

Work Phone

Please note: If you are providing this information, you are giving permission for us to contact you at work.

Preferred method of contact

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Email
Text
Mail

Referral Information

How did you find out about our practice?

If other, please specify

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name

Species *

If other species not listed above

Breed (If known)

Color

Date of Birth (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Pet Medical History

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccine (if known)

Is your pet on any medication or supplement?

Yes
No

If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?

Yes
No

If yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If yes, please comment on the conditions(s) and indicate if they are current or past conditions

Please use the following box to provide us with any other relevant information about your pet

Treatment Authorization & Financial Agreement

I hereby authorize the veterinarians at Belle City Veterinary Hospital to examine, prescribe for, and treat my animal(s). I understand that any problem that develops with my pet(s) will be treated as deemed best by the veterinarian, the staff, or a representative. I agree that the veterinarian shall do the exams, treatments, anesthesia, and or surgical procedures as discussed and agreed upon during the examination and treatment. I assume responsibility for all charges incurred in the care of my animal(s). I also understand PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE. I have read and understood this policy, and I accept responsibility for all fees. I understand that if I fail to pay as agreed, legal action will be taken against me. I also understand that there is a $35 fee on all returned checks. *

I agree

New Client Form

New Client Form

Owner's Information

Co-Owner's Information

Referral Information

Pet Information

Pet Medical History

Treatment Authorization & Financial Agreement

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