ALLANDALE VETERINARY HOSPITAL
484 Essa Road, Barrie, Ontario L4N 9E5 (705) 733-1422
PATIENT and CLIENT INFORMATION SHEET
Thank you for giving our hospital the opportunity to care for your pet.
So that we may be better able to meet your needs, please complete the following:
Owner Information
Name:
Spouse / Other:
Address:
City:
Prov:
Postal Code:
Home Phone:
Work Phone:
Spouse's Work Phone:
Cell Phone:
E-Mail:
If necessary, may we call you at work?
Yes
No
Place of employment:
Spouse's employment:
How did you become aware of our clinic? -
Yellow Pages
Personal Recommendation
From:
Hospital Sign
Other
MEDICAL INFORMATION
(Please fill out completely)
Date of your pet's last visit to a veterinarian:?
This is the first visit.
Name of previous Clinic:
May we call for medical records?
Yes
No
What is your reason for changing veterinarians?:
What prior illnesses, surgery or drug allergies has your pet had?:
Is your pet covered by pet insurance?
Yes
No
Do you consider your pet (s):
Part of the family
Just a pet
Pet Information
-
Pet #1
Pet #2
Pet #3
Pet #4
Name
Species (Dog, Cat, Other)
Breed
Colour
Pet's Birthday
Sex
M
F
M
F
M
F
M
F
Spayed / Neutered?
Yes
No
Yes
No
Yes
No
Yes
No
Pet Vaccination History / Dates
Cats and Dogs
Rabies
Distemper
Dogs Only
Parvo
Bordetella
Cats Only
Leukemia
PAYMENT POLICY:
Full payment is required upon rendering of services. Deposits may be required on major medical / surgical procedures, trauma cases and emergency work where hospitalization is required. We will gladly prepare a written estimate if you desire.
We do not carry open accounts. Payment must be made in CASH, DEBIT CARD (INTERAC), AMEX, VISA or MASTERCARD.
If for any reason payment cannot be made today, arrangements may be made with the Hospital Supervisor PRIOR to seeing the doctor.
NSF cheques will be charged a fee of $25.00 plus interest charges of 2% per month.
To prevent the spread of infectious diseases and parasites, hospitalized animals must be current on all vaccines and free of internal parasites. I authorize Allandale Veterinary Hospital to provide vaccines and parasite control when needed.
Signature of owner or authorized representative:____________________________________________________
Name:
Date :