Client/pet Information Sheet
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Complete Client/pet Information Sheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1Can we send you Text messages for
appt. reminders? ____YES
____NO
(_____)_________________________
DATE: ________________
Cell phone number
CLIENT/PET INFORMATION SHEET
Owner's Name ______________________________________________________________________________________________
LAST NAME
FIRST NAME
SPOUSE/PARTNERS' FIRST NAME
LAST NAME(IF DIFFERENT)
Address ___________________________________________________________________________________________________
NUMBER
STREET
CITY
STATE
ZIP
COUNTY
Phone Numbers (_____) _______________________ (_____) _________________________ (_____) ________________________
HOME
WORK
CELL NUMBER
Spouse’s Work Number
Spouse’s Cell
(_________) __________________________________________
(________) ______________________________________________________
Email address ___________________________________________________________________________________________________________
Please note: we will never share your email address with another organization.
May we send electronic reminders/newsletters to your email address?
Y
N
Who is primary decision maker for your pet?
__________________________________________________________________________________________________
Payment is expected at the time services are rendered. You are encouraged to discuss fees or ask for an
estimate in advance. We accept cash, checks, Visa, MasterCard, Discover, Amex and Care Credit (for
those that qualify).
We believe that practicing great medicine is our responsibility and payment is yours. Therefore, we do
not establish personal accounts.
Driver's License # ______________________________________________________________________ State _____________
Spouse/partners license #_____________________________________________________________________ State _________
Employer________________________ Employer's Address ________________________ City, State, Zip ______________________
How were you referred to Glendale Animal Hospital? ________________________________________________________________
PLEASE LIST EACH PET AND ITS INFORMATION BELOW:
Pet's Name ______________________________________ Breed________________________ Color__________________________
How were you referred to Glendale Animal Hospital? ________________________________________________________________
_________________________________________________________________
Species (dog, cat, ferret, etc.)________________________ Sex
M
F
Spayed/Neutered Birthdate ____________________
Pet's Name ______________________________________ Breed________________________ Color__________________________
Species (dog, cat, ferret, etc.)________________________ Sex
M
F
Spayed/Neutered Birthdate ____________________
I hereby authorize the staff of GAH to render any treatment which is deemed necessary to my pet(s) health while in the custody
of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to
contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be
financially responsible for all emergency procedures deemed necessary. I understand that all professional fees are to be paid at
the time services are rendered and a deposit is required on all pets admitted to the hospital.
___________________________________________________
Signature:
Circle one:
Owner
Agent
Good Samaritan
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