Owner Number One Last Name

Owner Number One First Name

Owner Number One Birth Date

Owner Number One Social Security Number (Needed to write checks in the future)

Owner Number One Address

Owner Number One City

Owner Number One State

Owner Number One Zip

Owner Number Two Last Name

Owner Number Two First Name

Owner Number Two Birth Date

Owner Number Two Social Security Number (Needed to write checks in the future)

Owner Number Two Address

Owner Number Two City

Owner Number Two State

Owner Number Two Zip

How did you find our clinic?

Saw the Sign    Saw the Yellow Page Ad     Received a coupon in the mail     Website    

Friend - may we thank them? Name

Pet's Name

Species    Dog     Cat     Ferret     Rabbit     Other

Breed

Birth Date

Approximate Weight in Pounds

Coloring and Marks

Current Medications

Current Food   Dry  Brand        

                       Can  Brand

Dog or Cat - Spayed? yes     no

Dog or Cat - Neutered? yes     no

Cat - De-clawed?  yes     no

Other surgeries? Please list -

Any other significant medical history that we need to know about?  Please list.

Do we have your permission to obtain your pet's prior medical history? yes   no

We feel it is important to have all the information about your pet before we begin treatment, if possible.  Thank  you.

Where are the prior records kept?  Who should we contact to get the records?

Phone Number and Address

By checking this box, I am allowing the staff at the Animal Clinic of Platte County, or others that they refer to in case of emergency, to treat this pet, now and any other time it is brought in during an emergency situation.

By checking this box, I understand that all fees for your pets must be paid in full at the time your pet is released.

Your Name