Weight __________ Temp __________ RR __________ HR __________ MM __________ CRT __________ All Pet Emergency Clinic (812) 422-3300 Patient # ________
*PLEASE PRINT*
OWNER INFORMATION
Last Name: ________________________________ First: _______________________________
Spouse Last: _______________________________ First: _______________________________
Street Address: __________________________________________________________________
City:
Home Phone: _________________________ Cell Phone:
__________________________
PAYMENT (Circle One): Cash / Check** / Visa / Master Card / Discover / Care Credit
** If paying with a check, please refer to the Policy Sheet posted in the exam room and fill in Employer Info.**
Employer Name: _______________________ Address: ___________________ Phone: _____________
Spouse’s Employer:_____________________ Address:____________________Phone: _____________
PET INFORMATION
Name _____________________________________ Circle: Dog / Cat / Other ______________
Breed _____________________________________ Female / Male Spayed / Neutered
Age _______________________ Color / Markings: _______________________________________
Has your pet been vaccinated within the last year? Yes / No By a Veterinarian? Yes / No Results:
Is your pet on a monthly heartworm preventative? Yes / No Tested for Heartworms? Yes / No (Pos. / Neg.)
Is your pet on a flea/tick preventative? Yes / No If
yes, date/time applied? _____________________
Please list any medications your pet is currently taking (including over the counter, heartworm, and flea medications):
__________________________________________________________________________________
Does your pet have a chronic disease or history of any illnesses (seizures, arthritis, diabetes, etc.)? Yes / No
If Yes, What? _____________________________________________________________________
Family/Regular Veterinarian or Clinic______________________________________________________
PAYMENT IS
DUE AT TIME OF SERVICE
**Please turn this document over after signing to fill in more
information regarding your pet’s visit.**
NO BILLING
DEPOSIT REQUIRED ON ALL ANIMALS
ALL
ANIMALS MUST BE PICKED UP BY 7:30 A.M.