Form Page: cah_info_sheet
Thank you for giving us the opportunity to take care of your pet. We will be happy to answer any questions you have about your pet's health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!
District of Columbia
Spouse's Cell Phone
Drivers License Number
How did you learn of our practice?
If recommended or referred, by whom?
PET HEALTH HISTORY
Date of last vaccines
Describe any prior illnesses.
You agree, in order for us to service our account, notify you of information pertaining to your account or medical condition, or for the purposes of collection, we may contact you by telephone at any number provided by you, including wireless telephone numbers. We may also contact you via e-mail or text message using any email address you provide. Methods of contact may include the use of pre-recorded and artificial voice messages and/or use of an automated dialing device.
We will gladly prepare a written estimate of services if you desire. Please ask your doctor or receptionist upon arrival.
All professional fees are due at the time services are rendered.
Type name as signature
There will be a service charge for any returned check.
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.
Method of payment