Client Intake Form

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Owner Information

Name(Required)

First Last

Email Address(Required)

Phone Number(Required)

Alternate Number(Required)

Spouse

Phone Number

Address(Required)

Street Address Address Line 2 City ZIP Code

Emergency Contact(Required)

Phone Number(Required)

Active/Retired Military(Required)

Yes (proof of Military ID)

Patient Information

Pet's Name(Required)

Birthday(Required)

Species(Required)

Dog

Cat

Exotic

Breed(Required)

Color(Required)

Sex(Required)

Male

Female

Unknown

Altered(Required)

Yes

Current on Vaccines(Required)

Yes

Do you have second pet?(Required)

Yes

Pet's Name(Required)

Birthday(Required)

Species(Required)

Dog

Cat

Exotic

Breed(Required)

Color(Required)

Sex(Required)

Male

Female

Unknown

Altered(Required)

Yes

Current on Vaccines(Required)

Yes

Can we use photos of your pet(s) on our Social Media platforms?(Required)

Yes

Previous Animal Hospital/Clinic(Required)

Reason for today's visit:(Required)

All professional fees are due at time of service. Payment plans are not accepted. We will gladly prepare a written estimate if you desire. Please ask your doctor or technician. We gladly accept Cash/Visa/Mastercard/Debit/Care Credit/Scratch Pay and personal checks.

All God's Creatures Veterinary Hospital will be staffed during normal hours only. Hospitalized patients will receive treatments and medications after hours as prescribed by the attending veterinarian. Phone calls after hours will be forwarded to a voicemail system. Any after hour medical emergencies should be referred to the local 24-hour animal emergency hospital. Please note that medications cannot be provided to a pet without a doctor/patient relationship. Medication refills will be ready within 24-48 hours of request unless otherwise notified. All appointments that show up later than 10 minutes are subject to a $25.00 late fee.

Signature(Required)

Date(Required)

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Owner Information

Patient Information

When you need us, we’ll be there.

Phone & Email

Address

Hours

Send a Message

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