Form - New Client Form

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete this form.

Primary Owner’s Name

Secondary Owner's Name

Primary Owner’s Mailing Address
City, State & Zip


Primary Owner’s Home Phone
Primary Email

Employer
Closest Relative
Not Living WIth You

Relative's Address
Relative's Phone

For reference purposes we require the following information. For your safety we do not share this information.

Owners Social Security or
Drivers License
How did you hear about us?

Secondary Owner’s Mailing Address
Secondary City, State & Zip


Secondary Owner’s Home Phone
Secondary Email

Animal Medical History
Pet Information
Pet 1
Pet 2
Pet 3
Pet 4
Name
Species
Breed
Color
Date of Birth / Age
Sex
Has Your Pet Been Altered?
Weight
 lbs lbs lbs

lbs

 
Vaccinations and Testing Date of Last Date of Last Date of Last Date of Last
Canine

Distemper/Parvo
Kennel Cough/Bordetella
Rabies
Other Vaccinations
Heartworm Test
Flea and tick
Dentistry

 

Feline

        
Distemper/Upper Res
Leukemia
FIB
Rabies
Other Vaccinations
FELV/FIV Test
Flea and tick
Dentistry
Previous Veterinarian
 Permission is hereby given to have records for the above animals transferred.
Additional Information

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We will gladly prepare a written estimate for any service upon your request. We accept the following methods of payment: Cash, Check, Master Card, Visa, American Express, Discover and Care Credit. For your convenience, your credit card number may be kept on file by completing our Auto Pay Form. This will allow your account balance to be paid or for use in an emergency situation. Please ask any staff member for the Auto Pay Form.

We do not have a 24-hour attendant. There will be periods of time that those animals hospitalized overnight will not be under direct supervision. Please feel free to inquire about our hospitalization policies.

I agree to pay for all professional services and medications rendered in the care of any animal I bring to PRESCOTT ANIMAL HOSPITAL. Furthermore, I understand that in order to prevent the spread of infectious disease and parasites, hospitalized and boarded animals must have documentation of current proof of vaccines and be free of parasites. I authorize Prescott Animal Hospital to provide vaccines and parasite control as needed for my pet.

 
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Companion Animals: 1318 Iron Springs Road Prescott, AZ 86305 • 928-445-2190 Fax: 928-445-1491

Equine Center: 2611 Avenger Road Prescott, AZ 86301 • 928-776-PONY (7669) Fax: 928-442-2497