Thank you for giving us the opportunity to care for your pet. We are happy to answer any questions you have about your pet's health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!

Pet Information

 


*My pet is a     Dog     Cat


*Gender
Male     Female     Not Sure

*Birthdate


*Spayed/Neutered
Yes     No     Not Sure


*Microchipped
Yes     No     Unsure

Vaccinated For DAP
(Distemper/Adenovirus/Parvo)

Yes     No     Not Sure

Vaccination Date:

Vaccinated For Bordetella

Yes     No     Not Sure

Vaccination Date:

Vaccinated For Rabies

Yes     No     Not Sure

Vaccination Date:

Vaccinated For Rattlesnake

Yes     No     Not Sure

Vaccination Date:

Vaccinated For Leptospirosis

Yes     No     Not Sure

Vaccination Date:

Vaccinated For FVRCP

Yes     No     Not Sure

Vaccination Date:

Vaccinated For FELV

Yes     No     Not Sure

Vaccination Date:

Vaccinated For Rabies

Yes     No     Not Sure

Vaccination Date:



Client Information

 










*Birthdate: 




 

     I am at least 18 years old and hereby authorize Old Town Veterinary Hospital to examine, prescribe for, and/or treat the above described animal (PET). I, as owner or acting on behalf of the owner, assume responsibility for all charges incurred in the care of this PET. I understand a deposit is required for surgical, diagnostic and/or emergency treatment and that these charges are due in full at the time of release. Veterinary care during nighttime hours is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during that time.

 

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