|
203 MOSER ROAD LOUISVILLE KY 40223 (502) 245-7863, FAX (502) 245-2869 |
VETERINARY
ASSOCIATES STONEFIELD
|
|
|
VETERINARY ASSOCIATES STONEFIELD PATIENT/CLIENT INFORMATION
Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a few moments to fill out this information sheet.
Owner’s Name Spouse/Other
Address City/State/Zip
Home phone # Work phone #
Owner’s SSN Spouse/Other SSN
Employer’s name/address
Spouse’s/Other’s Employer’s name/address
At what time and at what phone # is it best to call about your pet?
In case of EMERGENCY, call at phone #
E-Mail address:
We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered. If you wish to pay by check or credit card, please complete the following.
Bank Name: Driver’s License # Preferred Method of Payment: □ Cash □ Check □ Credit Card
Name of previous/current Veterinarian:
How did you hear of our hospital? Please choose one. □ Individual, someone we may thank? □ Previous client? Their name. □ Yellow pages or another telephone directory? □ Hospital sign? □ Another hospital? If so, which one? □ Other, please state:
To help prevent the spread of infectious diseases, ALL hospitalized and boarded animals must be current on all vaccines.
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on next page. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.
Signature Date
EXOTIC PATIENT HISTORY
Pet’s name
Bird Mammal Reptile Other
Breed Birth Date Sex
How long has the patient been ill?
Are there any other animals at home?
If so, what type?
Are they showing any signs of illness?
Have any animals died? Have any medicines been used?
If so, what kinds?
Has the patient been seen by another veterinarian?
If so, by whom, date last seen, and what for?
What food is used on a daily basis?
What type of water is used?
How often are food and water bowls changed and disinfected?
Where did the patient come from?
How long has the patient been in its present environment?
When was the last molt?
Have any pesticides or poisonous products been used around the cage?
If so, what?
Is the bird housed in a cage, allowed to free flight within house, or housed in flight pen?
Have you seen any personality/behavioral changes?
Is there any other information that we may find helpful in treating your pet?
What is the nature of your visit? |