New Client Intake Form
Animal Care Center
Surgical Booking Form
First Name
*
Last Name
*
Address
Street Address
City
State
Zip Code
Phone
*
Email
*
Patient Information:
Pet Name
*
Species:
*
Dog
Cat
Pet Age
*
Pet Breed
Pet Weight (lbs)
*
Sex
*
Male
Female
Please list all current medications and any additional notes for staff:
Previous Veterinarian (Name, City, State and Phone Number)
Consent
I the undersigned, do hereby certify that I am the owner of the above animal or duly authorized agent for the above animal. I hereby authorize Animal Care Centers, their agent or representative to perform medical or surgical procedures, anesthesia, radiographic procedures, administration of drugs or other such treatments which the veterinarian deems necessary. I agree to accept responsibility for the full payment of all services rendered at each visit. If the above animal is admitted to the hospital a deposit equaling no less than half the estimated cost of treatment will be required with the remainder of the actual cost due upon discharge. I hereby state that I have read this release and I understand this agreement.
I understand and agree.
Signature
Clear
Submit
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