Angel Animal Hospital

Client & Patient Information Form

Owners Name:
First:_______________________ Last:__________________________
Address:________________________________________________________________
City:_____________________________________________State:____Zip:___________
Home #(

)_______________Cell #(

)_____________ Work #(

)_____________

Preferred method of payment: Cash __ Credit Card __ Check __($35 returned check fee)
Drivers License:_______________________ Employer:_________________________
Are you a new client? Y / N
How did you hear about our office? Referred by: _______________________________
Website / Newspaper / Other:_______________________________________________

Pets Name:_____________________________________________________________
Microchip ID #_____________________ Are you interested in a Microchip? Y / N
Species: Dog / Cat / Other: ____________Sex: Male / Female Spayed?/Neutered?: Y/ N
Breed: ____________________________Color/Markings:________________________
Birth date/ Approximate age: ________________________If Cat: Indoor / Outdoor
Is this a new patient to our hospital? Y / N
Previous/ Current Vet: ____________________________________________________
Medical History (Please list any conditions, allergies, medications, vaccine history, etc.):

Any special concerns or questions? __________________________________________

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner)
of the animal described above and of 18 years of age or older. I understand that every effort will
be made to achieve a successful outcome, and to provide for all the possible safety in hospital
care and handling. I hereby authorize this hospital to receive, prescribe, treat, or perform surgery
upon the pet(s) on file and any additional pet I present. Furthermore, I agree to pay these fees in
full for the services rendered at the time the pet is admitted to the hospital. I understand that
veterinary service is not provided during nighttime hours. If I neglect to pickup my pet within
three (3) days of discharge date agreed upon and do not notify you within that time period, you
may assume that the pet is abandoned and are herby authorized to dispose of the pet as you deem
best or necessary.
Signature: ________________________________________ Date: _________________