Canine Check In Form

Animal Medical Center welcomes you and your dog.

Owner Name
First Last
Co-Owner Name
First Last
Home Phone
Cell Phone
Work Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Animal Information
Name
Breed
Color(s)
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Microchip?
Our Hospital Info
OUR HOSPITAL is open 6 days a week. We operate by appointments. Emergencies are taken when possible. Always call first, so we can be prepared for your emergency. Annual check-ups for each pet is ideal; and a must if there is an ongoing problem or in need of medication.
OUR HOSPITAL recommends current vaccinations for all our patients. Vaccinations are medical procedures having some risks. These risks include mild reactions such as soreness at the site of injection to more severe reactions of anaphylaxis or cancer developing at the site of injections.

OUR HOSPITAL recommends an annual stool sample and heartworm test for dogs not on a heartworm preventative. RECOMMENDED VACCINATIONS: DISTEMPER: potentially fatal virus of the immune system given as a series then as a booster on an annual basis. ADENOVIRUS TYPE 1: causes severe liver disease, given as a series then as a booster on an annual basis. PARVOVIRUS: potentially fatal intestinal virus, given as a series then as a booster on an annual basis. LYME/LEPTO: disease caused by the Borrelia burgdorferi organism/virulent Leptospira serovars RABIES: required by law to prevent the transmission of the fatal rabies virus.

OUR HOSPITAL considers each pet to be important, thus records are kept for each patient. These records are available for no fee via email, and can be accessed on our pet portal via our website. Printed records will require a fee.

FINANCIAL POLICIES: PAYMENT IS REQUIRED WHEN SERVICES ARE RENDERED. WE DO NOT BILL. WE ACCEPT CASH, M/C, VISA, DISCOVER, DEBIT AND PERSONAL CHECK (requires a social security number or license on file).
PET INSURANCE IS AVAILABLE.
Consent
If an account is sent to collection, the undersigned agrees to pay all amounts due plus collection fees of thirty-five (35%) percent of the unpaid balance. Returned Checks are a $25.00 handling fee. I understand payment procedures and assume my pet's financial expenses.
Consent
I authorize Animal Center to release records in cases of grooming, kenneling, and to other veterinary establishments in cases of emergencies.
Consent
I authorize Animal Center to use my pet's photos and medical history on social media sites and web blogs for raising awareness, showing medical cases, and any other publicized purpose.
Consent
I have read and understand the hospital policies and recommendations outlined on this form.
Today's Date
Date Format: MM slash DD slash YYYY

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