Download and Print FormOwners name* First Last Pet’s Name:*Age/Birthdate*Species* Dog Cat OtherOther*Breed*Sex* Male Female Neutered SpayedColor(s)*Distinguishing Markings*Has your pet had any of the following?* Allergies Heartworm disease Lyme Disease Kidney issues Liver issues Glaucoma Fleas or ticks Heart disease Feline Leukemia FIV Parvo disease OtherOther*Current Medications* Interceptor or Heartgard Frontline Plus Advantage (Multi, Advantix, Advantage II) Rimadyl PPA OTC vitamins Joint supplements OTC pain medication OtherOther*Is your pet current on their rabies?* Yes NoExpiration Date* MM slash DD slash YYYY Is your pet microchipped?* Yes NoMicrochip Number (if known)*Pet Insurance Company*Policy Number*Method of payment* Cash Check Card CareCreditAuthorization* I hereby authorize Animal Health Clinic to examine, prescribe for and treat my pets. I assume responsibility for all charges incurred in the care of my animals. I also understand that these charges will be due at the time of release and that a deposit may be required for surgical treatment or hospitalization. We will gladly prepare a written estimate for your pet's care at any time. Just ask one of our staff membersNameThis field is for validation purposes and should be left unchanged.Δ
