Patient/client Information Sheet - Knowles Animal Clinic

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Patient/Client Information Sheet
Thank you for giving Knowles Animal Clinics the opportunity to care for your pet.
So that we may become better acquainted, please complete the following:
PETS NAME:___________________________ Breed:___________________ Color:_______________________
Age:_________yrs_________mnth
Sex (circle one): Male / Female / Male Neutered / Female Spayed
Is your pet kept inside, outside, or both? ____________ Do you have other pets? _______________________
IF YOU HAVE BEEN REFERRED BY YOUR VETERINARIAN FOR A SPECIALIZED SURGICAL OR
MEDICAL PROBLEM, PLEASE BE AWARE THAT WE WILL TREAT ONLY YOUR PET’S PRESENT
PROBLEM. UNDER NO CONDITIONS WILL WE ACCEPT YOUR PET OR ANY OTHER FAMILY PET
FOR UNRELATED PROBLEMS, VACCINES, BOARDING, OR ROUTINE CARE UNLESS REFERRED
ONCE AGAIN BY YOUR VETERINARIAN. YOUR COOPERATION IS APPRECIATED.
Your signature: _________________________________________________________
Which clinic/veterinarian has your pet’s records? ____________________________________________________
Vaccinations (circle): Current or Due / If current, when was your pet last vaccinated? ___________________
For your pet’s safety, and the safety of others, we may need to verify his/her vaccines.
Is your pet on heartworm prevention? Yes or No / If yes, which brand? _______________________________
For your canines safety we recommend a heartworm test every 6 months or a minimum of once a year.
PERSON RESPONSIBLE FOR PET (OWNER):___________________________________________________________
Are you 18 or older? Yes / No
Address:_____________________________ APT#_________ City, State, Zip code:__________________________
Home phone:_____________________ Work phone:____________________ Cell phone:____________________
Place of Employment:___________________________________________________________________________
Where can we reach you during the day? ___________ Email Address:____________________________________
Spouse or other person to act for owner:________________________________ Phone:______________________
EMERGENCY CONTACT (friend/relative):_________________________________ Phone:_____________________

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