How did you hear about our hospital: [ ] American Animal Hospital Association Referral [ ] Individual: Someone we may thank?_____________________________________ [ ] Yellow Pages
[ ] Our Street Sign
[ ] Other____________________________
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED Signature________________________________________ We accept: Cash
* Check * Care Credit * Discover * American Express * Visa *
Master Card
*We will be happy to prepare a written estimate if you desire. Please ask the receptionist, technician or doctor. *I authorize my previous Veterinarian to release my pet(s) medical information to the Deer Park Animal Hospital doctors and staff. Signature___________________________________ *I authorize the Deer Park Animal Hospital doctors and staff to release my pet(s) vaccination history and information. Signature___________________________________ *To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccinations and free of internal and external parasites. I authorize the doctor to provide vaccinations and parasite control as needed for my pet. Signature___________________________________ Thank you for giving us this opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete both sides of this information sheet
New Pet Data Owner’s name ________________________________________________ Telephone___________________________________ Address ____________________________________ City_______________________ State/Prov__________ Zip/P.C.________ Previous DVM__________________________________________ Telephone__________________________________________ Alert Data (allergies, idiosyncrasies, etc.)_______________________________________________________________________
Pet 1 Pet name Species (cat, dog, bird, other) Breed Description/Color Age in years Date of birth Sex Spayed or neutered Pet origin (friend; humane society; shop) Length of time owned Registration ID# Diet/Type of food Hours spent outside each day
VACCINATION HISTORY: DHLP (Distemper: dog, ferret) Parvovirus (Parvo: dog) FVRCP (Infectious diseases: cat) Rabies (dog, cat, ferret) Feline Leukemia test Other vaccines Heartworm test Heartworm prevention Fecal exam (worms: dog, cat) Dentistry Prior illness Prior surgery
Pet 2
Pet 3
Website and Social Media Release Form I grant permission to the Deer Park Animal Hospital to take photos of my pet for the purpose of posting to the Deer Park Animal Hospital website or Facebook page. I hereby release and discharge Deer Park Animal Hospital from any and all claims arising out of use of these photos. I am above the age of 18. I have read the foregoing document and fully understand its contents. Deer Park Animal Hospital has the right to use: (pick one) Only my pet's first name(s) My pet(s) first name and my last name My pet(s) name and my first and last name Signature ____________________________________________________ Print Name ___________________________________________________ Email Address _________________________________________________
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