Client Information
Last Name: [esigtextfield name="esig-sif-1610133045063" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
First Name [esigtextfield name="esig-sif-1610133048296" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Middle / Suffix: [esigtextfield name="esig-sif-1610133051143" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Street Address: [esigtextfield name="esig-sif-1610133868682" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
City: [esigtextfield name="esig-sif-1610133873852" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
State: [esigtextfield name="esig-sif-1610133877861" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Zip Code: [esigtextfield name="esig-sif-1610133885746" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Primary Phone: [esigradio name="esig-sif-1610134078210" label=" " display="horizontal" verifysigner="undefined" labels="Home=&Cell=" required="1" ] [esigtextfield name="esig-sif-1610133890080" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Secondary Phone: [esigradio name="esig-sif-1610134098321" label="" display="horizontal" verifysigner="undefined" labels="Home=&Cell=" required="0" ] [esigtextfield name="esig-sif-1610133920443" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Email Address: [esigtextfield name="esig-sif-1610133933048" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Employer Information
Employer Name: [esigtextfield name="esig-sif-1610133936622" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Work Number: [esigtextfield name="esig-sif-1610138695410" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
City: [esigtextfield name="esig-sif-1610133943111" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
State: [esigtextfield name="esig-sif-1610133947415" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Zip Code: [esigtextfield name="esig-sif-1610138689443" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Emergency Contact Information
Emergency Contact Name: [esigtextfield name="esig-sif-1610138700565" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Emergency Contact Phone: [esigtextfield name="esig-sif-1610138946597" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Emergency Contact Relationship: [esigtextfield name="esig-sif-1610138704314" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
How did you hear about us: [esigcheckbox name="esig-sif-1610141326377" label="" display="horizontal" verifysigner="undefined" boxes="Website=0&Social%20Media=&Internet%20Ads=&Walk-In=&Building%20Sign=&Other=" required="0" ]
Other: [esigtextfield name="esig-sif-1610141402496" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Number of Pets in your household (please specify by species): [esigtextfield name="esig-sif-1610141409803" class="form-control" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Primary Reason for today’s visit?: [esigtextarea name="esig-sif-1610141675375" verifysigner="undefined" size="small" label="" displaytype="plaintext" ]
Pet Information
Pet Name: [esigtextfield name="esig-sif-1610141570784" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Species: [esigtextfield name="esig-sif-1610141495751" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Breed: [esigtextfield name="esig-sif-1610141495751" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Color: [esigtextfield name="esig-sif-1610141768710" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Sex: [esigtextfield name="esig-sif-1610141500445" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Age: [esigtextfield name="esig-sif-1610141759692" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Birth Date: [esigtextfield name="esig-sif-1610141763593" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
Neutered/Spayed: [esigradio name="esig-sif-1610141881113" label=" " display="horizontal" verifysigner="undefined" labels="Yes=&No=" required="1" ]
If Yes, at what age? [esigtextfield name="esig-sif-1610141771488" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
At what age was your pet obtained? [esigtextfield name="esig-sif-1610142019889" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="1" ]
From: [esigradio name="esig-sif-1610142081058" label="" display="horizontal" verifysigner="undefined" labels="Friend=&Breeder=&Pet%20Shop=&Humane%20Society=&Other=" required="1" ]
Other [esigtextfield name="esig-sif-1610142151494" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Reason for obtaining Pet: [esigcheckbox name="esig-sif-1610142334404" label="" display="horizontal" verifysigner="undefined" boxes="Companion=0&Protection=&Breeding=&Show=&Other=" required="0" ]
Other [esigtextfield name="esig-sif-1610142355071" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Describe your pet's diet: [esigcheckbox name="esig-sif-1610142684278" label="" display="horizontal" verifysigner="undefined" boxes="Canned=&Dry=" required="1" ]
Brand [esigtextfield name="esig-sif-1610142720673" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
List your pet's current medications: [esigtextfield name="esig-sif-1610144780582" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Microchip [esigtextfield name="esig-sif-1610142750241" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Please check any symptoms or problems you’ve noticed with your pet: [esigcheckbox name="esig-sif-1610142965699" label="" display="horizontal" verifysigner="undefined" boxes="Appetite%20Loss=&Gagging=&Sneezing=&Thirst=&Behavioral%20Changes=&Gums%20Bleeding=&Limping=&Coughing=&Vomiting=&Depression=&Scooting=&Weakness=&Breathing%20Problems=&Scratching=&Urination%20Increase=&Shaking%20Head=&Diarrhea=&Loss%20of%20Balance=" required="0" ]
Eye Disorders: [esigtextfield name="esig-sif-1610142752632" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Other: [esigtextfield name="esig-sif-1610143092747" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Pet’s History (check all that pet has received): [esigcheckbox name="esig-sif-1610144935425" label="" display="horizontal" verifysigner="undefined" boxes="Distemper=&Feline%20Leukemia%20Test%20=&Parvovirus%20(Dog)=&Rabies%20(Dog%20%2F%20Cat)=&Dental=&FVRCP%20(infectious%20Disease-Cat)%20=" ]
Prior Surgery: [esigtextfield name="esig-sif-1610143250273" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Prior Illness: [esigtextfield name="esig-sif-1610143258083" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Other: [esigtextfield name="esig-sif-1610143254513" verifysigner="undefined" size="undefined" label="" displaytype="plaintext" required="0" ]
Payment
Payment Method: [esigcheckbox name="esig-sif-1610143331974" label="" display="horizontal" verifysigner="undefined" boxes="Cash=&Visa=&Mastercard=&Discover=&AMEX=&Care%20Credit=" required="1" ]
(payment in full due at time of service)
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In the event this account is turned over for collection, I also agree to be responsible for attorney’s fees in the amount of 33 and 1/3% (percent) of the outstanding balance. I understand interest will accrue for any balance over 30 days at a rate of 1.5%.
