Engelberg Kristy Animal Hospital LLC 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 the information sheet. (Please print this and fill in prior to your office visit)

Owner's name___________________Spouse/Other________________________
Owner's Social Security #_____________
Spouse/Other SSN #_____________
Address_________________________ City__________________________State_______ Zipcode________
Home Phone #_______________________ Work______________ Cell__________
Employer's name and address______________________

At what time_____________and at what phone#______________is it best to call about your pet --In case of EMERGENCY, call_________________at phone #_________________________

We will gladly prepare a written estimate if you so desire. Please ask the Receptionist or the Doctor. Professional fees are due at time services are rendered. If you wish to pay by credit card or check, please complete the following.

Bank name______________________ Driver's License#___________________

Preferred Method of payment __Cash __Check __ Credit Card___

Name of your Previous /Current Veterinarian_______________________________________

How did you hear of our hospital?

__Individual, someone we may thank?

__Yellow pages or other directory

__Hospital Sign

__Another hospital? If so which?

__Other, please state:

Would you like to be on our mailing list? Email address_________
To help prevent the spread of infectious diseases. ALL hospitalized and boarded amimals 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 recieve, prescribe for, treat or perform surgery upon the pet(s) listed. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that veterinary service is provided during nighttime hours as necessary in the judgement of the veterinarian in charge.

Sign_______________________________________________________ Date____________

ANIMAL MEDICAL HISTORY

Pet's name_______________________________

Species________________________________

Breed___________________________________

Description/Color_______________________

Age or Date of Birth________________

Sex________________

Altered or Spayed__________

Diet (Name of brand of food)___________________

Daily Medicines, Vitamins or Treats__________

Shampoo/Flea Products Used_____________

Hours spent outdoors each day_____________

VACCINATIONS {write down most recent date}

DHLPP Distemper/Parvo-Dogs ____________

Bordetella (Kennel Cough) -Dogs _________

Lyme - Dogs____________

Rabies (Dogs/Cats) 1 year, 3 years___________

FVRCP (Infectious Diseases) Cats __________

FELV (Feline Leukemia) Cats ________

Other Vaccines - Please list ______________

Heartworm Test -Dogs _______________

Heartworm Prevention -Dogs______________

FELV or FIV test -Cats ______________

Fecal Test (Stool exam for worms) Dog/Cat____________

Dentistry --Date work was done ____________

Geriatric Health Screen ______________

Medical History- Prior Illnesses/Surgery _______________

Thank you