PATIENT AND CLIENT INFORMATION SHEET—
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Thank you for giving our hospital the opportunity to care for you and your pet. So that we may become better acquainted and maintain proper medical records as required by law, please complete the following.
Today's Date:
Salutation
Mr.
Mrs.
Dr.
Ms.
Owner's First Name:
Middle Initial:
Last Name:
Spouse's First Name:
Middle Initial:
Last Name:
Address:
Apt.:
City:
State:
Zip:
Home Phone:
Work Phone:
Spouse Work Phone:
E-mail:
Place of Employment:
Address:
Spouse's Employment:
Address:
If Necessary, May We Call You At Work?
Yes
No
How Did You First Become Aware Of Our Hospital?
Yellow Pages
Sign
Recommendation—Whom May We Thank?
Veterinarian (Name)
I Chose Your Hospital Over Others In The Area Because:
All fees are due when services are rendered. A deposit is required on all hospitalized pets and the balance is due when your pet is released from the hospital. We do not have a billing system due to the high cost involved in maintaining our hospital. You must be over eighteen years of age to authorize treatment. Please indicate your choice of payment. To pay by check, we ask that you have a driver's license. Thank You.
Cash
Check
Credit Card
ATM
Social Security #:
Driver's License #:
Date of Birth:
Thank you for giving us the opportunity to serve you.
