New pet intake form Owner /Guardian (required) Home Address (required) City (required) State (required) ---ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY zipcode (required) Cell telephone (required) Home telephone Work telephone Your email (required) Pet name (required) Date of Birth (required) Sex (required) FemaleMale Spay/Neuter (required) SpayedNeuteredNA breed (required) color (required) Indoor, Outdoor or Both Other Pets Identification (tattoo, microchip,etc.) (required) Would you like us to microchip? (required) YesNo Previous Veterinary Hospital Previous Medical History Is your pet currently on any medication(s) or special diet? (Heartworm, flea/tick control, supplements,etc) Payment: We accept: Cash, Visa, Mastercard, Discover, and American Express - with proper identification from established clients. Credit card numbers can be stored for ease of payment. If a card is on file then this form gives permission to process the card for the amount of service, unless another form of payment is stated at the time of patient arrival. Payment is expected at the time of service. Should the service of the collection agency be required, the client assumes all associated costs. Return policy: Returns cannot be accepted for any opened or used merchandise/products, or any medical products after they have left the hospital. By signing this form I agree all the information provided is accurate and I agree to the above terms. SIGNATURE Date How were you referred to our practice?