Pet Information Sheet - Crepe Myrtle Animal Hospital, Pa
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1Crepe Myrtle Animal Hospital, PA
Chart # ____________
Thank you for giving Crepe Myrtle Animal Hospital, PA the opportunity to care for your pet. So that we may become
better acquainted, please complete the following:
Client Information
Dr./Mr./Mrs./Ms. ___________________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Spouse’s Name _____________________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Street Address _______________________________________ City ________________ State _______ Zip __________
Mailing Address ______________________________________ City ________________ State _______ Zip __________
Home Phone (________)________-________________ Cell Phone
(________)________-________________
Place of Employment ___________________________ Work Phone
(________)________-________________
Spouse’s Employment __________________________ Spouse’s Work (________)________-________________
Email _____________________________________________________________________________________________
Driver’s License # _______________________ State _________
Date of Birth ________/________/___________
(required)
How did you hear about our hospital?
Phone Book _____ Hospital Sign _____ Internet _____ Other __________
Were your referred by a client of ours?
No _____ Yes ______ Their name ________________________________
(so we may thank them)
Patient Information
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Name
______________
______________
______________
______________
______________
Species
______________
______________
______________
______________
______________
Breed
______________
______________
______________
______________
______________
Age/DOB
______________
______________
______________
______________
______________
Color
______________
______________
______________
______________
______________
Gender
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
Spayed/Neutered
Have any of your pets been seen by a veterinarian before? If so, which vet? ______________________________________
__________________________________________________________________________________________________
Would you like to be present during the treatment of your pets?
No __________ Yes __________
Payment is expected at the time services are rendered. We accept payment by cash, local check*, Visa,
MasterCard, Discover, American Express, and Care Credit.
*Your driver’s license must be presented each time a check is presented for payment of services. All checks will be
verified through Equifax. There will be a service charge of $30.00 for any returned checks.
Please Sign: I agree that I am financially responsible for the above listed pets and agree to pay all fees incurred at time of treatment.
This agreement is in force from this date until I notify the hospital in writing to the contrary.
Signature _______________________________________________________
Date ____________________________
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