Address__________________________City___________State_____________Zip________

      Home Phone______________Best time to call_____________E-Mail_____________________

      Place of Employment______________________________Work Phone___________________

      Spouse’s Employment_____________________________Work Phone___________________

      Social Security Number_____________________ Spouse’s SS #________________________

v   How did you become aware of our hospital?        Yellow pages___ Hospital Sign___ Other___

       Personal Recommendation - who should we thank____________________________________

v I feel that my pet is another member of our family___                I feel it is just a pet___

       I wish the best medical care for my pet___            I have limits to what I wish done___

v Reason for today’s visit? _______________________________________________

v Pet’s name____________________________ Dog___ Cat___ Bird___ Reptile___ Other_____

       Breed/Species_________________________ Color_____________ Date of birth___________

       Male___ Female___ Spayed/Neutered? _____

       Does your pet have any illnesses or conditions we should know about?___________________

       Is your pet currently on any medications? ____ Please list them___________________________

       Does your pet have any allergies to drugs or foods? ____________________________________       

       Is your pet current on Heartworm testing? ___ Is your pet on Heartworm preventative?_________       

       Has your cat has been Feline Leukemia and Feline AIDS tested_____ results_________________

       Is your pet on a flea/tick preventative? ______________________________________________

       Are your pets’ vaccinations current? ______

                             Dogs: DHLPC-Parvo___ Rabies___ Bordetella___ Lyme___

                             Cats: FVRCPC___ Rabies___ FeLV___ FIP___

                             Ferret: Distemper___ Rabies___

       Have your pets been seen by another veterinarian? ___ Who shall we call to confirm the patients

                             history and vaccination status?_________________________________________

       Has your pet recently been checked for Internal Parasites? _______________________________

       I have had this pet for ______ years.   My pet spends ______ hours a day outside.

       I feed ___________diet _____ times daily.  I brush my pets’ teeth___ times each _____________

       Do you have any other pets at home?

                              Name______________________ Species________________ Breed____________

                              Name______________________ Species________________ Breed____________

                              Name______________________ Species________________ Breed____________

v   Payment is required at the time of service...we accept Cash, Check, Visa and MasterCard

           I, the owner, understand that a 2% fee will be charged on the unpaid balance at the end of each 
       month, and my account will be sent to collections. In the event my account is collected through an  
       attorney at law, or any other collection agent, acting on behalf of The Animal Hospital of  Lynchburg, 
       I, the owner, agree by signing below to pay all costs incurred for collection including court costs and 
       attorney's or collection fees.

Owner Signature: _____________________________________       Date: _______________________