Welcome Letter

Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you may have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!

Owner

Spouse

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Home #

Cell #

Work #

Email(Required)

Would you prefer to receive reminders by email or regular mail?

Regular Mail

Spouse Work #

Spouse Cell #

Emergency Contact Name

Phone #

How did you learn about us?

Yellow Pages

Location

Sign

Recommendation

If recommended, by whom:

Pet Health History

Name of Pet

Type

Dog

Cat

Other

Breed

Color

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Male Neutered

Female Spayed

East Paulding Animal Hospital is dedicated to providing outstanding medical care for all of our patients. All pet foods we carry are guaranteed by the manufacturer for 100% customer satisfaction. All other sales are considered final after the services are rendered, if you have concerns please contact us and we will work with you to try and resolve them as quickly as possible.

Authorization

I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release, that I am responsible for any accrued finance charges for any unpaid balances, and that a deposit may be required for treatment. If there is an unpaid balance and the account is sent to collections, there will be a $50.00 fee.

Signature(Required)

Date

MM slash DD slash YYYY

Mode of Payment

Cash

Debit

Check

Visa/MC

Amex/Dise

Care Credit

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