client/petinformationSheet

"*" indicates required fields

Owner's Name*

Spouse/Other

Address*

City*

State*

Zip*

Primary Phone*

Primary Phone Type

Home

Cell

Work

Secondary Phone

Secondary Phone Type

Home

Cell

Work

Spouse/Other Primary

Spouse/Other Primary Type

Home

Cell

Work

Spouse/Other Secondary

Spouse/Other Secondary Type

Home

Cell

Work

Email Address*

For Pet Desk reminders & hospital communication only

Owner's Birthdate*

MM slash DD slash YYYY

Mandatory for CURES reporting in order to dispense certain medications

Emergency Contact*

Phone*

How did you find out about Western Vet Group?

Referred by

Hospital Building/Sign

Hospital Website

Yelp

Search engine

Other

Referred by

(Please let us know who so we can thank them!)

Search engine

Other

Photo & Social Media Release

Western Veterinary Group asks permission use photographs of you and/or your pet with or without your name and for any lawful purpose, including, for example, such purposes as social media posts, publicity, illustration, advertising, and Web content. Please check one of the following: (required)

Photo & Social Media Release Types*

Yes, you may use photos of me and/or my pet

Yes, you may use photos of my pet, but NOT me

Please do NOT use photos of myself or my pet

Hospital Information

(Initial to the left of each item listed below)

Western Veterinary Group is not a 24-hour facility and is not staffed overnight. If our doctor(s) feel your pet is not stable & in need of 24 hour care, we may refer you to a trusted local 24-hour facility for continued care.*

We have a pharmacy on the premises, and an online pharmacy with Covetrus (vetsfirstchoice.com). Please be advised Western Veterinary Group does not work directly with pharmacies outside of Western Veterinary Group or Vets First Choice. However, if you wish to work with a different pharmacy, we are happy to supply you with a written prescription that you may to take to or mail in to your local or online pharmacy of choice.*

Fees are due at the time of services rendered and a deposit is required at the time of drop off for any pet being admitted to the hospital for procedure(s) and/or hospitalization. A written treatment plan will be provided for client authorization prior to services and a copy will gladly be provided to you upon request.*

Accepted payment types: Visa, MasterCard, American Express, Discover, CareCredit, Trupanion Express, Scratchpay and Cash. We do NOT accept personal or business checks.*

Please read and sign the following authorization:

I hereby authorize Western Veterinary Group and its staff to render any treatment deemed necessary to my pet(s) health while in custody of the hospital. I understand that in the event of any unusual or emergency circumstance, the staff will make every attempt to contact me before proceeding with treatment. I understand that veterinary medicine is a practice and that no treatment guarantees a cure or definitive diagnosis. I understand that I will be financially responsible for all services including treatment plans provided to me in person and over the telephone.

Client Signature*

Date

MM slash DD slash YYYY

Patient Section

Patient 1 Name*

Age or D.O.B.*

Species*

Canine

Feline

Other

Species (Other)

Breed*

Sex*

Male

Female

Spayed/Neutered*

Yes

Microchip #

Color(s)

Distinguishing Marks

Is this pet insured*

Yes

Company

Policy #

Vaccine/Medical History

Does your pet have history of any of the following? (Please describe)

DHPP

MM slash DD slash YYYY

Bordetella

MM slash DD slash YYYY

Rabies

MM slash DD slash YYYY

Influenza

MM slash DD slash YYYY

Heartworm Test

MM slash DD slash YYYY

Fecal

MM slash DD slash YYYY

Blood Test

MM slash DD slash YYYY

Feline

FVRCP

MM slash DD slash YYYY

Feline Leukemia

MM slash DD slash YYYY

Rabies

MM slash DD slash YYYY

FeLV/FIV Test

MM slash DD slash YYYY

Fecal

MM slash DD slash YYYY

Blood Test

MM slash DD slash YYYY

Vaccine Reaction(s)

(Please let us know which vaccine(s) and describe the reaction)

Does your pet have history of any of the following?

(Please describe)

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Previous Veterinarian Hospital

May we call for records?

Yes

Patient 2 Name

Age or D.O.B.

Species

Canine

Feline

Other

Species (Other)

Breed

Sex

Male

Female

Spayed/Neutered

Yes

Microchip #

Color(s)

Distinguishing Marks

Is this pet insured

Yes

Company

Policy #

Vaccine/Medical History

Does your pet have history of any of the following? (Please describe)

Does your pet (2) have history of any of the following?

(Please describe)

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Previous Veterinarian Hospital

May we call for records?

Yes

Patient 3

Patient 3 Name

Age or D.O.B.

Species

Canine

Feline

Other

Species (Other)

Breed

Sex

Male

Female

Spayed/Neutered

Yes

Microchip #

Color(s)

Is this pet insured

Yes

Company

Policy #

Vaccine/Medical History

Does your pet have history of any of the following? (Please describe)

Does your pet (3) have history of any of the following?

(Please describe)

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Previous Veterinarian Hospital

May we call for records?

Yes

Patient 4

Patient 4 Name

Age or D.O.B.

Species

Canine

Feline

Other

Species (Other)

Breed

Sex

Male

Female

Spayed/Neutered

Yes

Microchip #

Color(s)

Is this pet insured

Yes

Company

Policy #

Vaccine/Medical History

Does your pet have history of any of the following? (Please describe)

Does your pet (4) have history of any of the following?

(Please describe)

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Previous Veterinarian Hospital

May we call for records?

Yes

Patient 5

Patient 5 Name

Age or D.O.B.

Species

Canine

Feline

Other

Species (Other)

Breed

Sex

Male

Female

Spayed/Neutered

Yes

Microchip #

Color(s)

Is this pet insured

Yes

Company

Policy #

Vaccine/Medical History

Does your pet have history of any of the following? (Please describe)

DHPP

MM slash DD slash YYYY

Bordetella

MM slash DD slash YYYY

Rabies

MM slash DD slash YYYY

Influenza

MM slash DD slash YYYY

Heartworm Test

MM slash DD slash YYYY

Fecal

MM slash DD slash YYYY

Blood Test

MM slash DD slash YYYY

Feline

FVRCP

MM slash DD slash YYYY

Feline Leukemia

MM slash DD slash YYYY

Rabies

MM slash DD slash YYYY

FeLV/FIV Test

MM slash DD slash YYYY

Fecal

MM slash DD slash YYYY

Blood Test

MM slash DD slash YYYY

Does your pet have history of any of the following?

(Please describe)

Vaccine Reaction(s)

Medical Conditions or Allergies

Aggressive/fearful tendencies

Vaccine Reaction(s)

Aggressive/fearful tendencies

Medical Conditions or Allergies

Previous Veterinarian Hospital

May we call for records?

Yes

Appointment Date and Time (if already scheduled):

Appointment Date

MM slash DD slash YYYY

Appointment Time

Hours

Minutes

AM/PM

Notice of Abandonment

If, after (5) days from the date of written notice, your pet is not picked up it will be considered abandoned and may be adopted out, humanely euthanized, or handled in any manner deemed appropriate by Western Veterinary Group. It is understood that this does not relieve me from paying all of the fees for services, use of hospital, cost of keeping the animal, or collections fees. By signing below I acknowledge I have read and understand the Notice of Abandonment and that I am the owner of the pet(s) listed above.

Client Signature

Date

MM slash DD slash YYYY

Western Veterinary Group also offers a variety of additional services such as:
Boarding, Bathing, Acupuncture, Cold laser treatment, and more!
Please see a Client Service Representative for details.