Healthcare Pet Animal Intake Form

Healthcare Pet Animal Intake Form

Practice Information

Clinic/Practice Name:

Attending Veterinarian:

Owner / Responsible Party Information

Pet Information

Pet Name:    Species: Dog Cat Other

Date of Birth / Age (if DOB unknown):    Sex: Male Female Unknown

Spayed/Neutered: Yes No    Microchip #:

Vaccination & Preventive Care

Rabies:    Distemper/DA2PP:

Bordetella (Kennel Cough):    Other Vaccines/Notes:

Emergency Contact

Insurance / Financial Responsibility

Pet Insurance Provider:    Policy/Member #:

Subscriber Name:    Subscriber Phone:

I acknowledge that I am financially responsible for all charges incurred regardless of insurance coverage. Payment is due at the time services are rendered unless other arrangements are approved in writing.

Medical History

Is the animal aggressive or likely to bite? Yes No

Consent for Examination and Treatment

I, the undersigned Owner/Authorized Agent, hereby authorize the veterinarians and staff of the named practice to examine, prescribe for, anesthetize, perform surgical and diagnostic procedures, and otherwise treat the animal identified above. I understand that the practice will exercise reasonable care but that no guarantee can be made as to results.

I acknowledge that anesthesia, surgery and certain medical treatments involve risk, including but not limited to adverse drug reactions, organ dysfunction, neurologic injury, and death. I have had an opportunity to ask questions about recommended procedures, alternatives, and risks. I consent to the administration of sedatives, anesthetics, and analgesics as deemed necessary by the attending veterinarian.

In the event of an emergency and reasonable attempts to contact me have been unsuccessful, I authorize the attending veterinarian to perform emergency treatment as necessary to prevent undue suffering or death. I understand that emergency treatment will be billed in accordance with the clinic's fee schedule and I am financially responsible for such charges.

Authorization to Release Records and Photographs

I authorize the practice to release medical records or photographs of the animal to other veterinary facilities, referring veterinarians, or as required by law. I also authorize the use of clinical photographs for treatment records, education, or practice promotion unless I indicate otherwise below.

Do you permit the clinic to use photographs of your pet for educational or promotional purposes? Yes No

Additional Terms and Acknowledgements

I certify that I have disclosed all known medical conditions and behavioral concerns. I understand that failure to disclose relevant information may increase the risk of complications. I accept financial responsibility for all services rendered and authorize release of records to my insurer if requested. I understand that estimates provided are not guarantees and that unexpected conditions may result in additional charges.

I understand I may withdraw consent for non-emergency procedures at any time prior to the procedure, subject to reasonable cancellation fees for scheduled surgeries or specialized diagnostic services.

Owner Certification

By signing below, I certify that I am the legal owner or authorized agent for the animal identified on this form, that the information provided is true and complete to the best of my knowledge, and that I have authority to consent to the treatments described. I acknowledge receipt of any required clinic notices and accept financial responsibility for services rendered.

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