Weight __________

Temp __________

RR __________

HR __________

MM __________

CRT __________

 

All Pet Emergency Clinic

104 B. South Heidelbach Ave.

(812) 422-3300

 

Patient # ________

 
†††††††††††††††

 

 

*PLEASE PRINT*

 
 

 

 


OWNER INFORMATION

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

Last Name:________________________________ First:_______________________________

Spouse Last: _______________________________First:_______________________________

Street Address: __________________________________________________________________

City:________________________________State:______________________Zip: ________

Home Phone:_________________________Cell Phone:__________________________

PAYMENT ††††† (Circle One):††† Cash/Check**/Visa†† /Master Card/Discover/Care Credit

** If paying with a check, please refer to the Policy Sheet posted in the exam room and fill in Employer Info.**

Employer Name: _______________________ Address: ___________________ Phone: _____________

Spouseís Employer:_____________________ Address:____________________Phone: _____________

PET INFORMATION

Name _____________________________________†††† Circle:†† Dog/Cat/Other ______________

Breed _____________________________________††††††††††† †††††††† Female / Male††††† Spayed / Neutered

Age _______________________†† Color / Markings:_______________________________________

Has your pet been vaccinated within the last year? Yes / No††† By a Veterinarian? Yes / No†††††† †††† Results:

Is your pet on a monthly heartworm preventative? Yes / No†† Tested for Heartworms? Yes / No (Pos. / Neg.)

Is your pet on a flea/tick preventative? Yes / No†††††††††††††† If yes, date/time applied?_____________________

 

Please list any medications your pet is currently taking (including over the counter, heartworm, and flea medications):

__________________________________________________________________________________

Does your pet have a chronic disease or history of any illnesses (seizures, arthritis, diabetes, etc.)?Yes / No

If Yes, What? _____________________________________________________________________

 

Family/Regular Veterinarian or Clinic______________________________________________________

 

PAYMENT IS DUE AT TIME OF SERVICE

 
**Please turn this document over after signing to fill in more information regarding your petís visit.**

 

 

NO BILLING

 
 


DEPOSIT REQUIRED ON ALL ANIMALS

†††† ALL ANIMALS MUST BE PICKED UP BY 7:30 A.M.