Today's Date: (required)
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Spouse/Other: Do any children live with this pet? (Please list first names and ages) Owner's E-Mail Address (required) : May we contact you at work? (required) Work Phone Number + Ext (if applicable) Employer's Name & Address: What time and which phone number is the best to call about your pet? (If you prefer to be contacted by email, please write “email” in the space below). (required) In case of an EMERGENCY who may we call and at what phone number? (required) How did you first hear of our hospital? (required) If you were referred by an individual or heard about us from another source, please specify: We will gladly prepare an estimate for you upon request.
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
We accept Cash, Check, Visa, MasterCard, American Express, Discover and Debit Cards.
We require a DRIVER’S LICENSE NUMBER on file. Driver's Licence State: (required) Driver's Licence Number: (required) (Driver's License Information will be kept strictly confidential)
Consent to Treatment and Financial Responsibility
I hereby authorize Animal Hospital of Warwick, PC to examine, prescribe for, and treat my
pet(s). I further authorize the Animal Hospital of Warwick, PC to provide vaccines and parasite
control as needed for my pet(s) to comply with all applicable laws and to prevent the spread
of infectious diseases and parasites. I understand that Animal Hospital of Warwick, PC cannot
guarantee success of any treatment provided for my pet(s), and that I am responsible for
payment of all charges incurred regardless of the results, at the time services/treatments are
rendered. Click here to agree to the above statement. Appointment Date & Time (required)
:
Animal Identification and Medical Information (Complete the pet information for each of your pets and submit).
Pet's Name: (required) Species (i.e. Dog, Cat, Rabbit, etc.): (required) Breed: (required) Description / Color: (required) Date of Birth: (required) Sex (required) Length of Time Owned: (required) How/where did you acquire your pet? (required) Microchip Number: Hours/Time spent outside daily: (required) Heartworm / Internal Parasite Prevention Product Used: (required) Is this product used continuously, all year? (required) Flea / Tick Prevention Product Used: (required) Is this product used continuously all year? (required) Current Medications: Diet: (required) Prior Illness/Injury: Prior Surgery/Dentistry: Do you have any prior vaccine history to provide? (If so, please give records to the receptionist to make a copy for your pet’s record at the time of visit). (required) If not, may we call your pet’s previous veterinarian and request a copy of records to be made part of your pet’s permanent record with us? Previous Veterinarian (Name, Address and Phone Number): Date & Time of Appointment: (required) Additional Comments or Concerns?
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