Welcome to Iron Hills Animal Hospital
Client Information:
Date: _____________________________
Drivers License: _____________________________________________________
Name (Last, First Middle Initial) __________________________________ Spouse/Partner __________________________________
Date of Birth: _______________________________________________ Social Security No. _________________________________
Address: _____________________________________________________________ City/State/Zip ___________________________
Home Phone: (_______)________________________
Email: ___________________________________________________
Cell Phone: (_______)________________________
Employer: ________________________________________________
Work Phone: (_______)________________________
Employer Address: _________________________________________
Emergency Contact Name: __________________________
Phone: (_______)______________________________________
How did you learn about our practice? __________________________________________________________________
Number of pets (please specify by type): _________________________________________________________________
Primary reason for visit? ______________________________________________________________________________
Pet Information:
Pet’s Name _______________________________________
◊ Dog
◊ Cat
◊ Other ______________________
Sex: ◊ M ◊ F ◊ Neuter/Spay Age: ___________ Birthdate: _____________ Breed: _____________________________
Neuter/Spay at what age?: _____________________________
Color: ________________________________________
What age was pet obtained? __________________________________________________________________________
From: ◊ Friend
◊ Breeder
◊ Pet Shop
◊ Humane Society
◊ Other _______________________________________
Reason for obtaining pet (check all that apply): ◊ Companion ◊ Protection ◊ Breeding ◊ Show ◊ Other ___________
Describe your pet’s diet: ______________________________________________________________________________
List your pet’s current medications: _____________________________________________________________________
Please check any symptoms or problems you’ve noticed with your pet:
◊ Appetite Loss
◊ Gagging
◊ Behavioral Changes
◊ Gums Bleeding
◊ Breathing Problems
◊ Inappropriate Elimination
◊ Coughing
◊ Limping
◊Depression
◊ Loss of Balance
◊ Diarrhea
◊ Scooting
◊ Eye Disorders: ________________
◊ Scratching
Pet’s History (check all that pet has received):
◊ Distemper
◊ Feline Leukemia Test
◊ Parvovirus (Dog)
◊ FVRCP (Cat)
◊ Rabies
◊ Lyme (Dog)
Authorization
◊ Shaking Head
◊ Sneezing
◊ Thirst
◊ Urination Increase
◊ Vomiting
◊ Weakness
◊ Other ________________________________
◊ Prior Surgery: _________________________
◊ Prior Illness: __________________________
◊ Other: _______________________________
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of the
animal, including interest charges of 1.5% per month. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
Signature of client responsible for pet(s) ___________________________________ Date: ________________________