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Transcription:

REGISTRATION Client Information Office Use Only Client #:... Last Name First Name Driver s license # Street Address (DO NOT USE PO BOX ADDRESS).... City State Zip Code ( ) -. ( ) -. ( ) -. Home Phone # Cell Phone # Work Phone # @... E-mail address Spouse/Other s Name Place of Employment How did you hear about us? (please circle one) Yellow Pages.com Phone Book Sign (walk-by) InYourArea.com VetsNearYou.com OTHER: (please elaborate): Friend (if so then whom?):. The Person who referred you will receive a $25.00 medical credit! PET S INFORMATION: Pet s.. Spayed or neutered? Name Sex Yes No... RabiesTag # City License tag # Birthday Age. <breed>... Breed Color Species (inside or outside).. Allergies Microchip # Where does your pet sleep?. PREFERRED METHOD TO RECEIVE LAB RESULTS: E-MAIL PHONE CALL CHECK HERE IF YOU WOULD NOT LIKE YOUR PET FEATURED ON OUR SOCIAL MEDIA PAGES AND WEBSITE. I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, OR TREAT ABOVE PET. I ASSUME RESPONSIBILITY FOR ALL CHARGES THAT OCCUR IN THE CARE OF ABOVE PET. I ALSO UNDERSTAND THAT ALL CHARGES MUST BE PAID AT THE TIME OF SERVICES. SIGNATURE OF OWNER : DATE (must be 18 years of age or older)

Abbey Animal Hospital is staffed during normal hospital hours which are: Monday, Wednesday, Friday Tuesday and Thursday Saturdays Sundays 7:30AM to 6:00PM; 7:30 AM to 7:00PM; 8:00AM to 1:00PM. CLOSED Hours Abbey Animal Hospital is NOT staffed are: Monday, Wednesday, Friday Tuesday and Thursday Saturdays from 6:00 PM ~ 7:30 AM the following Morning from 7:00 PM ~ 7:30 AM the following Morning from 1:00 PM ~ 7:30 AM on Monday Morning -Please be advised that all pets that are not picked up by the closing of any given day will be boarded at the owners expense. -Pickup time for boarding is 2:00 PM. If pet is picked up after pick-up time then additional charges will apply. Exceptions are Grooming and Doggie Daycare. -Drop off time for boarding is Monday, Wednesday, and Friday between 8:00AM and 5:00PM, Tuesday and Thursday between 8:00AM-6:00PM, and Saturday 8:00AM-12:00PM. AFTER HOURS: Sundays, and holidays, staff members or the doctors make rounds to feed, walk, and medicate all animals staying in our facility. However, constant monitoring is NOT AVAILABLE after hours. Emergency hospitals are available to provide treatment; monitoring, and hospitalization for post surgical or critical care animals when our hospital is closed. I have Read, understand and shall comply with the above policy. I also understand that Abbey Animal Hospital is not staffed after hours. Signature (must be 18 years of age or older) Date Print Name WITNESS

PAYMENT POLICY Unfortunately due to some credit abusers, PAYMENT IS DUE AT THE TIME THE SERVICE IS RENDERED. As we receive no charitable donations or government subsidy this policy will ensure Abbey Animal Hospital will be able to continue to provide quality care to all its patients. 1. PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. We accept cash, Care Credit, and all major credit cards. 2. THERE WILL BE A $25.00 CHARGE FOR FAILURE TO SHOW FOR YOUR SCHEDULED APPOINTMENT WITHOUT CONTACTING US TO CANCEL OR RESCHEDULE PRIOR TO YOUR APPOINTMENT TIME. 3. All surgeries must be paid for upon picking up your pet. 4. In all emergency cases an emergency deposit of estimated treatment costs is required. Any additional balance is due upon completion of treatment. 5. Please feel free to discuss fees for services before those services are performed. A written treatment plan can be made upon request. Treatment plans are only an ESTIMATE and not to be considered a final quote. 6. NO CASH REFUNDS. SALES OF ALL medications and prescriptions are final. 7. Any credit on account will be void after 12 months WE MUST POINT OUT THAT OBTAINING PROFESSIONAL SERVICES KNOWINGLY WITHOUT INTENT OR ABILITY TO PAY, OR WRITING A BAD CHECK CONSTITUTES FRAUD UNDER THE LAWS OF VIRGINIA. I have read, understand and shall comply with the above payment policy Signature (must be 18 years of age or older) DATE Print Name WITNESS

NEW PET QUESTIONAIRE Pet s Name_ Your name:_ 1.) Do you have any other pets? If Yes please circle species and number you have: Canines Felines Birds Reptiles Pocket Rabbit Ferret Other (Please list): 2.) When was your pet s last visit to the vet and what was he/she being seen for? Previous Veterinarian: 3.) Has your pet ever had a vaccine reaction to your knowledge? If yes, please list vaccine & treatments received: 4.) I acknowledge that my pet is: ( ) NOT AGGRESSIVE to my knowledge ( ) Food/Water/Toy AGGRESSIVE ( ) Cage AGGRESSIVE ( ) Animal AGGRESSIVE ( ) AGGRESSIVE & WILL BITE 5.) Is your pet spayed/neutered? [ ] Not to my knowledge [ ] Yes If yes, when did the surgery take place?

6.) Please check all that apply to your pet s medical history: [ ] Hyperthyroidism [ ] Food allergies [ ] Has Seizures [ ] Hypothyroidism [ ] Autoimmune Deficiency [ ] Has Arthritis [ ] Heart Murmur [ ] On special diet for bladder stones [ ] Blind [ ] Diabetic [ ] On special diet for renal failure [ ] Deaf Other problems: 7.) Does your pet have any allergies? [ ] None I m aware of [ ] Yes; please list below: 8.) Is your pet currently on any medications including heartworm/flea prevention? If yes please list: 9.) Has your pet had any recent surgeries? If so when and what type: 10.) Any other special care instructions you d like the doctor to know?

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