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Henrietta
Animal Hospital, PLLC
Patient/Client
Information
Welcome to
Henrietta Animal Hospital. Thank
you for giving us the opportunity to care for your pet.
Please help us meet your needs better by taking a moment to
complete this information sheet.
Your Name/Title
________________________ Spouse/other
_______________
Address
_______________________ City ___________ State ___ Zip _______
Home Telephone
__________________ Your Work Telephone _____________
Your Email Address
_______________________________________________
Spouse/Other Email
Address ________________________________________
Your Employer
__________________ Employer Telephone ________________
Spouse Employer
_______________ Employer
Telephone ________________
Your Driver’s
License Number __________________ State ___ (if paying by check)
In case of
EMERGENCY, please call ____________________________ at telephone
____________________
How do you prefer
to be notified of reminders?
Phone Message ____
Email ____ Post Card ______
How did you first
learn of our hospital? We
would like to thank any individual who referred you.
Hospital Sign ____
Direct Mail ____ Brochure ____ Yellow Pages Ad ____ Newspaper ____ AAHA
Referral _____ Referred By: _____________________
How do you consider
your pet? As part of your
family ____ Just a Pet ____
AT
YOUR REQUEST WE WILL GLADLY DISCUSS THE COST OF SERVICES AND/OR PREPARE
A WRITTEN ESTIMATE FOR RECOMMENDED PROCEDURES.
PROFESSIONAL
FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
DEPOSITS
MAY BE REQUIRED FOR PETS BEING ADMITTED.
We accept cash,
checks drawn from a local bank, debit cards, VISA, MasterCard, Discover
Card. We charge $20 fee for
returned checks.
TO PREVENT THE
SPREAD OF INFECTIOUS DISEASES AND PARASITES, WE RECOMMEND ANIMALS BE
CURRENT ON ALL VACCINES. PETS
WITH FLEAS WILL BE TREATED WITH A TOPICAL OR ORAL FLEA MEDICATION ON
ADMISSION, AND THE PRESCRIPTION PRICE WILL BE INCLUDED IN THE INVOICE. I AUTHORIZE ADMINISTRATION OF VACCINES AND PARASITE CONTROL
AS NEEDED FOR MY PET(S).
SIGNATURE
_________________________________ DATE ____________
Please list
Individual Pet Information
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PET #1
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PET #2
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PET #3
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Name
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Cat or Dog?
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Breed
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Description/color
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Age
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Date of Birth
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Sex/Altered
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Length of
Time Owned
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How Obtain
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Previous
Hospital/Vet
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Microchip #
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Vaccinations
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DHPP
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Bordetella
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Rabies
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FVRCP
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FELV
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Any Other
Vaccines?
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Groomer
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Kennel
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Current
Medications
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Special Diet
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Prior
Illness/Accidents
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Prior
Surgery/Dentistry
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Details
__________________________________________________________
________________________________________________________________
________________________________________________________________
We are collecting
information on breeders to refer to clients that ask. Please let us know if you would recommend your pet’s
breeder, their name, phone number and where located.
_________________________________________________________________________
Please tell us of
any other information we should have to best assist you and your pets.
Wel ____ TY ____
Phy Add ____ Email ____ DL ____ Sig ____ Policy ____
Remind ____Emp ____
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