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You may save time by printing and filling out this form before your pet's first visit. We operate by an appointment schedule so please call 971-3500 to make sure we schedule time for you pet's visit. Name: __________________________ Social Security Number: ____________________ Address:___________________________________ Home Phone: __________________ City:_____________________________ State: ___________ Zip Code: ____________ Employer: _________________________________ Work Phone: ___________________ Emergency or Cellular Phone: ____________________ Email: _______________________ Spouse or Pet's Co-Owner: ______________________ Work Phone: _________________ How did you hear about Old Dominion Animal Hospital? Referred by: __________________________________________ (We'd like to thank them.) _________Phone Book/Yellow Page Ad _________Drove By Hospital _________www.olddominionanimalhospital.com _________Other Pet's Name: ________________________________ Pet's Birth Date: _______________ Species: _________________ Breed: ___________________ Color: ______________ Female - Spayed: Yes ____ Date: ____________________ No ____ Male - Neutered: Yes ____ Date: ____________________ No ____ Vaccination History: Please indicate when your pet last received these vaccinations.
Heartworm Prevention: Are you currently giving your dog a heartworm preventative? Yes ____ No ____ Brand/Type: ______________________ Size or Color Code: _______________________ Dental Care: Has your pet ever had his/her teeth cleaned? Yes ____ No ____ If yes, when? _____________________ Are you brushing your pet's teeth? Yes ____ No ____ Are you giving your pet dental chew treats? Yes ____ No ____ Nutritional Information: What do you feed your pet? Dry _______________________ Brand ________________ Canned ____________________ Brand ________________ Special Diet _________________ Brand ________________ Do you give your pet table scraps? Yes ____ No ____ Do you give your pet vitamins or supplements? Yes ____ No ____ Does your pet have any medical conditions we should know about? __________________________________________________________________________ __________________________________________________________________________ Does your pet have behavioral problems you'd like to discuss? __________________________________________________________________________ __________________________________________________________________________ Has your pet been microchipped for identification? Yes ____ No ____ If yes, what is your pet's identification number? _________________________________ If no, would you like your veterinarian to discuss how easy it is to have your pet safely and permanently identified as yours if he/she is ever lost or stolen? Yes ____ No ____ Are there other pets in your household? Yes ____ No ____ If yes, how many?: Dogs ______ Birds ______ Ferrets ______ Cats ______ Reptiles______ Other ______ Payment is expected at the time services are rendered. We accept payment by cash, check, Visa, and Mastercard. A deposit may be required for major medical or surgical cases or for emergency services. Accounts must be paid in full before hospitalized pets may be released. We have no desire to extend anyone beyond their means and will gladly advise you on anticipated costs for the care of your pets. How do you plan to pay today? Cash ____ Check ____ Visa ____ Mastercard ____ Signed: _______________________ Date: _________________________ | ||
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