New pet intake form Primary Owner /Guardian (required) Home Address (required) Apt# City (required) State (required) ---ALAKAZARCACOCTDCDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code (required) Cell telephone (required) Home telephone Work telephone Your email (required) Additional Owner/Contact Name Telephone for Additional Contact. Pet name (required) Date of Birth / Approximate Age (required) Sex (required) FemaleMale Spay/Neuter (required) SpayedNeuteredNA Species (required) Breed (required) Color (required) Microchip Number Would you like us to microchip? YesNo Previous Veterinary Hospital Previous Veterinary Hospital Phone 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, Master Card, Discover, American Express and CareCredit. Credit card numbers can be stored on file 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 provided. Payment is required at time of service. Should the service of a 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?