Client name
(Required)
Patient name
(Required)
Contact phone
(Required)
Alternate phone
Enter email
(Required)
Reason for today's visit
How long has pet been showing signs?
(Required)
Is patient eating normally?
Yes
No
If no, how many days?
Has there been any vomiting?
Yes
No
If yes, how many times a day, and how long?
Is patient having diarrhea?
Yes
No
If so, for how long?
Additional Services while visiting today
Toe Nail Trim
Microchip
Bath
Vaccines
Ear cleaning
Flea preventative
Heartworm preventative
Anal gland expression
(Required)
Untitled
(Required)
I, the undersigned owner, am responsible for seeking veterinary care for the pet identified above and certify that I am eighteen years of age or older. I consent to the examination of this pet by Dr. Vergel and staff of Crystal Creek Animal Hospital. I also understand that services will not be performed until I consult with a staff member and approve an estimate.
I agree to assume financial responsibility for the associated charges for my pets’ care and will payment via cash, credit/debit card, check, or care credit at the time services are rendered. I agree that if I fail to comply with this policy, the hospital may handle this abandonment in a manner that is in the best interest of the pet and the hospital.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY