PATIENT / PET OWNER INFORMATION

The doctors and staff would like to welcome you and your pet to Gage Animal Hospital. We appreciate the opportunity to assist you in caring for your pet. Please help us meet your needs by taking a moment to complete the following information:

PET OWNER INFORMATION:

Date: ______________________

Owner’s Name: ____________________ Address: ______________________________

City: __________________ State: _____ Zip: _________ Home Phone: _____________

Occupation: _________________________ Employer: ___________________________

SSN: ______________ KS Driver’s Lic #: _____________ Work Phone #: __________

Spouse (Other): ___________________ Employer: ______________________________

SSN: ______________ KS Driver’s Lic #: _____________ Work Phone #: ___________

PET INFORMATION:

Pet’s Name: _____________________ Age: _______ Breed: _____________________

Species: Dog ____ Cat ____ Rabbit _____ Other ______________________________

Color: ______________________ Sex: ________ Spayed/Neutered: ________________

Present Diet: _____________________________________________________________

Reason for Visit: _________________________________________________________

Has your pet received vaccinations in the last 12 months? Yes [ ] No [ ]

Has your pet been checked for worms within the last 12 months? Yes [ ] No [ ]

Is your pet currently on heartworm preventative? Yes [ ] No [ ]

Previous veterinarian(s) where your pet has been seen: ___________________________

I assume financial responsibility for all charges incurred in the treatment and care of my pet. I also understand that these charges are payable at the time my pet is released from Gage Animal Hospital and that a deposit may be required prior to medical or surgical treatment.

Signed: ___________________________________ Date: _____/_____/_____

(Owner or Responsible Agent)

We will gladly prepare a written fee estimate prior to treatment. To request a written fee estimate, please ask the receptionist or the attending veterinarian and we will prepare one for you. We accept cash, personal checks, Mastercard, Visa and American Express. Please indicate below your method of payment.

[ ] Cash [ ] Personal Check [ ] Mastercard [ ] Visa [ ] AMEX