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NORTHSIDE VETERINARY CLINIC CLIENT INFORMATION Thank you for giving us the opportunity to care for your animal(s). Please fill out the following form completely. REFERRED BY _____________________________ OR ___YELLOW PAGES, OR ____DROVE BY, OR OTHER _______________________ OWNER’S NAME _______________________________ SPOUSE _______________________________ STREET ADDRESS ______________________________________________________________________ CITY _____________________________ STATE _________________ ZIP _________________________ HOME # (_____)______________________ CELL PHONE #(______)__________________________ E-MAIL ADDRESS _______________________________________________________________________ OWNER’S DRIVER’S LICENSE # ________________________________________________________ ISSUING STATE____________________ DATE OF EXPIRATION __________________________ EMPLOYER______________________________________________________________________________ EMPLOYER ADDRESS __________________________________________________________________ WORK # (______)____________________________ EXT. _____________________________________ Upon request, we will gladly prepare an estimate before any services are performed. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be updated at the time of your appointment if it is not current. 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 the following page(s). Furthermore, I agree to pay for fees for services rendered at the time the pet is discharged from the hospital. I agree to pay for the costs of collection in the event that collection efforts become necessary. I understand that a service fee of $30.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. SIGNATURE __________________________________ DATE ______________________ NORTHSIDE VETERINARY CLINIC PATIENT INFORMATION PET NAME ____________________________ OWNER’S LAST NAME ________________________ PET’S DATE OF BIRTH _______________ K-9 __________ FELINE ________ BREED __________________________ MALE _______ FEMALE _________ SPAYED ___________ NEUTERED ___________ COLOR/MARKINGS _____________________________________________ IS YOUR PET MICROCHIPED? YES _____ NO _____ MICROCHIP # ____________________ PREVIOUS HOSPITAL/CLINIC __________________________________________________________ ADDRESS _______________________________________ STATE ______________ ZIP ____________ TELEPHONE # (_____)____________________ MAY WE CALL TO GET YOUR PET’S RECORDS? YES _______ NO ________ IS YOUR PET CURRENT ON VACCINES? YES _______ NO ________ DAILY FOOD DIET ___________________________ AMOUNT FED _____________________ DO YOU GIVE YOUR PET TREATS? YES _______ NO _________ LIST ALL DAILY/WEEKLY MEDICATIONS AND THE DOSAGE FOR EACH: ________________________________________________________________________ ________________________________________________________________________ IS YOUR PET ON HEARTWORM PREVENTATIVE? YES ______ NO ________ IF YES, WHAT KIND OF PREVENTATIVE AND WHEN WAS THE LAST TIME YOU GAVE IT? _____________________________________________________________________ IS YOUR PET ON FLEA PREVENTATIVE? YES ______ NO ________ IF YES, WHAT KIND OF PREVENTATIVE AND WHEN WAS THE LAST TIME YOU GAVE IT? _____________________________________________________________________ MEDICAL HISTORY-PRIOR ILLNESS OR SURGERY ___________________________________ __________________________________________________________________________________________