Client Information

Name *

First

Last

Spouse/Co-Owner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

I consent to receive SMS text messages from All Creatures Pet Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Secondary Phone

Email *

Employer Name

How did you become aware of our hospital? *

Who can we thank for the referral? *

If other, please specify *

Patient Information

Pet's Name *

Species *

If other, please specify *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Reason for visit *

Does your pet have any allergies, sepcial medications, or health problems we should know about? *

Yes
No

If yes, please specify *

What type of food does your pet eat (type of food, brand, amount, etc.)? *

What type of treats does your pet eat (type, brand, amount, etc.)? *

Vaccination/Medical History

Date of last DHPP (distemper/hepatitis/parainfluenza/parvo) vaccination *

Date of last rabies vaccination *

Date of last kennel cough vaccination *

Date of last heartworm test *

Date of last intestinal parasite exam *

What heartworm/flea preventative is your dog currently on? *

Date of last FVRCP (rhinotraceitis/calcivirus/panleukopenia) vaccination *

Date of last rabies vaccination *

Date of last feline AIDS/leukemia vaccination *

Date of last intestinal parasite exam *

What heartworm/flea preventative is your cat currently on? *

Your pet must be free of internal and external parasites, including fleas, ticks and mites. If not, we will treat your pet at your expense. *

I have read and understand

Payment is required when services are rendered. Deposits are required on all hospitalized patients. We accept cash, Care Credit, and other major credit cards. We would be happy to provide an estimate of services upon request. *

I have read and understand

I hereby authorize All Creatures Pet Hospital, it's representative, agent or employees, to perform the surgery and/or other services requested or needed on the described animal, and do hereby release and forever discharge All Creatures Pet Hospital, its representative, agent or employees, from all claims and demands whatsoever which I have or may have against All Creatures Pet Hospital, its representative, agent, by reason of said surgery, administration of drugs or performance of other services, any consequences resulting directly or indirectly therefrom. *

I have read and understand

I further certify that I have ordered, or have been authorized by the owner to order the named services for the described animal. I further understand that every effort will be made to contact me in the event that my pet may require additional medical attention while on these premises, however I understand that my pet will be treated as deemed best by the staff veterinarian in the event you are not available for timely consultation. *

I have read and understand

I assume full responsibility for the treatment expense incurred. I understand that any animal not called for when notified, that the hospital shall designate for its release shall be considered abandoned by me and shall be disposed of at the discretion of the hospital. My financial responsibility shall not in any way be altered by such disposal and my indebtedness shall include all charges made against such animal up to and including the date of, and charges for, disposal of same. *

I have read and understand

Should your account become over thirty (30) days delinquent there will be a finance charge of 1.825% a month or 21.9% annually. *

I have read and understand

I (we) direct that this be effective for the present and each subsequent admission of any animal owned by me (us), such authorization being terminated only by delivery to the above Hospital and staff of written cancellation of this authorization. The right of exemption to personal property and wages under the constitution and laws of the State of Alabama is hereby waived in favor of the payment of the obligation; and undersigned agrees to pay all costs of collection, including attorney fees. *

I have read and understand

Signature *

Clear Signature

Today's Date *

Client Registration Form