Thank you for giving us the opportunity to care for your pet. Please help us to better meet your needs by taking a few moments to fill in all the requested information on this sheet.Owner's Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse/Co-Owner Name First Last Spouse/Co-Owner PhoneSpouse/Co-Owner Email Is address the same as primary owner? Yes NoAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?* Location Sign/Driveby Facebook Yellowpages Google Search WebsiteWho? So we can thank them!Pet InformationName*Species* Dog CatColor*Breed*Sex:* Male Female Neutered SpayedCurrent on Vaccinations?* Yes NoWhich hospital?*Age or DOB*Add another pet?* Yes NoName*Species* Dog CatColor*Breed*Sex:* Male Female Neutered SpayedCurrent on Vaccinations?* Yes NoWhich hospital?*Age or DOB*PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE PERFORMED We will gladly prepare a written Estimate for all procedures/treatments for your pet.DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON THEIR RABIES VACCINATIONUnvaccinated pets will be given their rabies vaccine before treatment or surgery.. To help prevent the spread of infectious diseases, hospitalized and boarded pets must be current on all vaccinations by a licensed veterinarian. Vaccinations can be updated at the time of your appointment if not current.I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care & handling. I hereby authorize Best Friends Animal Hospital to receive, prescribe for, treat or perform surgery upon my pet(s) as listed and any additional pet(s) I may present. Furthermore, I agree to pay fees for services rendered at the time my pet(s) is discharged from Best Friends Animal Hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that all past-due accounts will be charged interest on the unpaid balance at the rate of 1.5% per month. I understand that a service fee of $25 will be assessed for each non-sufficient fund check. I understand that continuous presence of a licensed doctor is not provided after regular business hours, however, it may be the judgment of the veterinarian in charge that after hours care is necessary for my pet and a qualified veterinary assistant will be present with my pet overnight with the doctor being on call. If overnight care is not available at Best Friends Animal Hospital, I understand that this service is currently provided by the Animal Emergency Center and I am responsible for any charges incurred at the AEC separately. If I neglect to pick up my pet(s) within 3 days of the discharge date and do not notify Best Friends Animal Hospital within that time period, Best Friends Animal Hospital may assume that I have abandoned my pet(s) and are hereby authorized to dispose of my pet(s) as Best Friends Animal Hospital deems best and/or necessary.* I give Best Friends Animal Hospital permission to request medical records from other veterinary hospitals, if needed, for the best care of my animal(s). I also give Best Friends Animal Hospital my permission to release my animal’s medical records to other hospitals, if needed for the best care of my animal(s)Signature*
