Alpharetta Animal Hospital-New client form

Owner Information

OWNER'S NAME

CO-OWNER'S NAME

ADDRESS

HOME PHONE

OWNER'S CELL

CO-OWNERS CELL

EMAIL ADDRESS

EMERGENCY CONTACT NAME

EMERGENCY CONTACT NUMBER

HAVE YOU HAD PETS HERE IN THE PAST?

Yes

No

Pet Information

PET NAME

SPECIES*

Dog

Cat

BREED OF PET*

AGE OF PET*

COLOR*

SEX*

Male

Female

NEUTERED/SPAYED

Yes

No

DO YOU HAVE PET INSURANCE?

Yes

No

WHO MAY WE THANK FOR REFERRING YOU?

INFORMED CONSENT

INFORMED CONSENT I am financially responsible for the patient described above and agree to pay all fees incurred for the care of such patient. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee the successful outcome of any such procedure. This agreement is in force indefinitely from this date forward unless I notify Alpharetta Animal Hospital in writing to the contrary.

I understand the total payment is due at the time service is rendered.

PLEASE SIGN*

DATE*