Patient And Client Information Sheet - Sunset Cliffs Animal Hospital printable pdf download

Patient and Client Information Sheet

Thank you for giving our hospital the opportunity to care for your pet.

So that we may become better acquainted, please complete the following:

Owner(s):

Mr. Mrs. Ms.:_________________________________ Spouse/Partner________________________

Last name,

First name

Address:_________________________________________________________________________

Street

City

State

Zip code

Primary Phone: (

)_________________ E-mail address:_______________________________

Secondary Phone: (

)___________________Occupation:_______________________________

How did you become aware of us: Yellow Pages____ Referral ___ Other _____________________

Name of place or person who referred you ____________________________

Patient Information

Pet’s name

Species

Breed

Sex

Color Birth date

Spayed/ neutered Microchip/ID #

1.________________________________________________________________________________

2.________________________________________________________________________________

3.________________________________________________________________________________

4.________________________________________________________________________________

5.________________________________________________________________________________

AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT

I, the undersigned, owner of admitted patient, hereby authorize Sunset Cliffs Animal Hospital to

administer such treatment as is necessary, to perform any surgical procedure as deemed necessary on

the basis of findings during the course of the examination. In most cases, an estimate will be made up

and full consent will be obtained before services are rendered. However, in the case of an emergency,

life-saving procedures may be necessary and may be performed without prior consent. I understand

that even in this case, every effort will be made to contact me beforehand. I assume full financial

responsibility for all charges incurred to patient and consent to release of any medical information. I

hereby certify that I have read and fully understand the above authorization for medical and surgical

treatment and agree to its terms.

PAYMENT IS DUE, IN FULL, AT THE TIME SERVICES ARE RENDERED!!!

_________________________________

______________

______________________

Signature of owner or guardian

Date

Method of payment

Driver’s license:______________________

-If paying by Check-

Social Security #:____________________

___________

Entered By

Patient And Client Information Sheet - Sunset Cliffs Animal Hospital

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