Star Meadow
Animal Clinic
1073
Revolutionizing Animal Care in the
Home Hours and Location Our Services Our Veterinarians Our Support Staff
The Essentials of Wellness Medicine A Picture Tour of Our Facility
NEW
CLIENT INFORMATION
Name: ______________________________ Spouse:_____________________________
Address: ______________________________________________ Zip: ______________
Phone: (home) _______________ (work) ______________ (cell) _______________
E-Mail Address:_______________________________________________________
Place of employment: _____________________________________________________
Who can we thank for recommending our hospital? Welcome Wagon Yellow Pages
Sign Advertisement Pets Press Farmington/Avon Life
Client’s Name_____________________________________
Tell us about your pets!
Name
Age Breed Sex Altered?
Color
1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
Which type of food do you feed your pets?_____________________________________
_______________________________________________________________________
Are any of your pets on any medication or special diets? Please explain______________
________________________________________________________________________
Do any of your pets have known drug allergies? Please explain_____________________
________________________________________________________________________
Do your pets take heartworm and flea/tick medication on a monthly basis? Y____N____
If you are a dog owner, do any of your dogs demonstrate aggressive behavior towards other dogs?
________________________________________________________________________
What do you look for in a veterinary hospital? __________________________________
________________________________________________________________________
Which animal hospital did you visit previously? (please include city and state if not local)
________________________________________________________________________
Are you interested in:
Dental Services Microchip
Flea & Tick Control Boarding
Heart Worm Prevention Pet Nutrition
Behavioral Consultation Obedience Training
Other___________________________________
I understand that all charges are to be paid at the time services are rendered, or at discharge, and that a deposit is required for inpatient services. I understand that the hospital staff will provide an estimate of current and anticipated charges for any hospitalizations. By signing below, I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.
Signature_____________________________________________Date______________