Forms



What phone number should be the primary phone number?
Home PhoneCell PhoneSpouse's Phone

How did you hear of us, from a friend or family member (please let us know their name so we can thank them)?
or
ad in paperad on radioYellow pagesinternet

How will you be planning to pay?
CashCheckCharge (Visa, Mastercard, Discover)Care Credit

Do you have pet insurance? YesNo

May we send a text message to the cell phone number provided above to confirm appointments and remind you of services that are coming due? YesNo

Are you at least 18 years of age? If no, we will need parent or guardian authorization to treat your pet(s). YesNo

PET INFORMATION

Pet No. 1
Sex: MaleMale NeuteredFemaleFemale Spayed



Pet No. 2 DogCat
Sex: MaleMale NeuteredFemaleFemale Spayed



Pet No. 3 DogCat
Sex: MaleMale NeuteredFemaleFemale Spayed



AUTHORIZATION

I hereby authorize the Doctors of At Home Veterinary Care to examine, prescribe medication for and/or treat the pet(s) listed on the back of this page. I assume responsibility for all charges incurred in the care of this/these animal(s). I also understand that all professional fees are due at the time services are rendered and that a deposit may be required for some treatments. I also grant At Home Veterinary Care permission to post my pet(s) picture, story and medical information on social media. I also understand that there are closed circuit cameras in each exam room.