Client Information Form

Complete your client information form online before your visit.

Client Information Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name of Owner (Over 18) *

First

Last

Your name if Not the Owner

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Phone:

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Home

Cell

Work

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Previous/Alternate Vet

Phone Number

Email Address for Reminders *

Pet Information

Pet #1

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Name *

Breed *

Color *

Sex *

Spayed/Neutered *

Age/DOB *

Pet #2

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Name

Breed

Color

Sex

Spayed/Neutered

Age/DOB

Reason For Visit

Is your pet current on vaccines? *

Is your pet currently taking any medication (including heartworm prevention)? *

Does your pet have any medical conditions, drug/vaccine allergies, or special requirements we should know about? *

Payment is required at the time of service. For your convenience, we accept most Credit Cards, Cash, Check* or Care Credit* (*both with matching & valid driver’s license).

A deposit will be required for all hospitalized animals. I hereby grant authority to the Veterinarian(s) and support staff in charge of the care of the pet described above to administer and treatment, or to administer such anesthetics and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this pet. Any animal left three (3) days without prior arrangements being made is considered abandoned and will be disposed of as permissible by law.

Dillon Animal Hospital reserves the right to refuse any and all services to any aggressive animal.

Customer Signature *

Clear Signature

Date *

Dillon

Email

Client Information Form