URGENT CARE AT DAVIS ANIMAL HOSPITALPlease take a moment to fill out the form below while you are waiting to be seen. Client Information Name * First Name Last Name Spouse/Other Name First Name Last Name Relation to Client Spouse Significant Other Relative Friend Other Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Spouse/Other Phone (###) ### #### Do you wish to receive yearly reminders via email? * Yes No, I go elsewhere for vaccines. Email Do you prefer texts or phone calls? * Text Phone Call Are you one of the following? (Please show your I.D. to a staff member). * 10% off services if you are Military, Law Enforcement, Paramedic, or Firefighter. Thank you for your service! Military Law Enforcement Paramedic Firefighter Not Applicable Patient Information Current Veterinary Office * Presenting Concern Today: * Patient Name * Date of Birth (Approximate is ok) * MM DD YYYY Species * Canine (dog) Feline (cat) Other Breed * Sex * Male Female Unsure Neutered/Spayed? * Yes No Unsure Color * Is your pet microchipped? * Yes Yes, but I don't know the number No No, but I'm interested in getting one Microchip number: Does your pet have any of the following: * Allergies Previous Surgeries Diagnosed Illnesses/Injuries None of the above. If you checked any box above, please explain: Please list your pet's medications here including heartworm and flea prevention: * Media Release Authorization * Pet owners and their pets are often photographed for use in Davis Animal Hospital promotional materials and publicity efforts. These photographs may be used in a publication, print ad, direct-mail piece, electronic media (e. g. video, CD-ROM, Internet/World-Wide Web)or other form of promotion. By selecting yes you release Davis Animal Hospital and all employees from liability for any violation of any personal or proprietary right in connection with such use. I give permission. I do not give permission without contacting me first. Medical Inquiry & Release Authorization * I give permission for the doctors and staff of Davis Animal Hospital to release or inquire about necessary medical information and vaccination status concerning my pet from other animal care professionals such as other veterinary hospitals, animal control, boarding facilities, grooming facilities, rescue or shelter organizations or other related animal care professionals. Current vaccination status may also be obtained from us by the health department or landlord. I give permission. I do not give permission without contacting me first. Treatment Authorization * I am the owner/authorized agent for the animal named above, and I am 18 years of age or older. I give permission for the doctors and staff of Davis Animal Hospital to examine and treat my pet as I have requested. I understand that medical therapy of any kind involves some risk to my pet, including but not limited to adverse drug reactions, and agree to hold the hospital and its employees harmless in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event of an emergency I understand that life saving measures will be initiated while an attempt is made to contact me. If I cannot be contacted at the listed numbers, the doctors and staff are directed to make decisions deemed best for my pet. I understand that payment is due when services are rendered, and I agree to pay for those services rendered. I understand that interest will accrue on any balance outstanding over 30 days at 1.5% per month (18% annually) and a $5.00 handling fee will be assessed on each monthly statement. I agree to pay for these and any additional cost incurred by the hospital in the collection of any outstanding debt for services rendered. I agree to the above. E-Signature * Typing my initials confirms that the above information is accurate to the best of my knowledge. Thank you!
