*Your Name
*Your Email
Spouse/Partner/Co-owner:
*Your Address:
*City:
*Zip Code:
*Primary Phone:
Secondary Phone:
How Did You Hear About Us? Sign / LocationApplewood Pet ResortInternet (Tell us where below)Other (Describe below)Personal Referral (Tell Us Who We Can Thank Below)
We occasionally like to share patient photos on social media. Do you give us permission to use your pet’s photos? Yes, my pet was born to be a STAR!No, my pet is shy
Pet's Name:
Pet Type:--DogCatOther (If other, describe below)
If other:
Pet's Breed:
Pet Gender:--MaleFemale
Spayed/Neutered?--YesNo
Date of Birth:(If unknown, approximate age)
Color:
Would you like us to obtain your pet’s medical record from another veterinarian to update our records? yesno
If yes, doctor/hospital name:
Do you already have an appointment scheduled with us? yesno
If yes, when?
Financial, Medical information and Liability Release I understand every effort will be made to achieve a successful outcome and to provide for all possible safety issues in hospital care and handling. I hereby authorize Applewood Animal Hospital to receive, prescribe for, treat and/or perform surgery upon the pet(s) listed herein and additional pets I present. I understand that no guarantees have been made as to the results of medical and/or surgical treatment. I agree to release Applewood Animal Hospital and its staff from any liability resulting from the treatment, surgery and/or hospitalization of my animal(s). I certify that I am over 18 years of age and am the owner or owner’s authorized agent of animals identified on the Patient Information Form. I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I assume full responsibility for all charges incurred in the treatment of my pets. I agree that in the event that any unpaid balance is referred to a collection agency, I will be responsible for all collection fees, legal fees and court costs and my owed balance may substantially increase.
I Agree
