MY VET ANIMAL HOSPITAL
WELCOME TO MY VET ANIMAL HOSPITAL!
Thank you for your interest in our practice. Please complete this information form to facilitate
the check-in process at your first visit. You can complete the automated form online and submit
or bring a printed copy in for your first appointment. Please be sure to contact our Client Care
Coordinator today to schedule your appointment!
CLIENT INFORMATION (Primary Caregiver)
Last Name:_______________________________First Name:_________________________
Address:___________________________________________Apt/Unit Number:__________
City:_____________________ State:________ ZIP Code:____________
Primary Phone:________________________ Secondary Phone:_______________________
Email:____________________________________
*Please note the primary contact will receive calls with results and reminder emails*
**Your email address will be kept private and will only be used in correspondence regarding your pet's
medical needs including yearly vaccination reminders, Exam Report Cards, and invoices**
ADDITIONAL CLIENT INFORMATION:
Partner/Spouse Last Name:______________________ First Name:______________________
Address:________________________________________ Apt/Unit Number:_______________
City:_____________________ State:________ ZIP Code:____________
Primary Phone:_______________________ Secondary Phone:_________________________
Email:____________________________________
PATIENT(S) INFORMATION:
Pet's 1
Pet's 2
Name
Gender (including
spayed or neutered)
Species (Canine or
Feline)
AAHA Accredited: We’re Setting the Standard of Veterinary Excellence
"Best Vet," in Chicago Reader's Best of Chicago 2010
info@myvetanimalhospital.com | www.myvetanimalhospital.com
Pet's 3
MY VET ANIMAL HOSPITAL
Breed
Color
Date of Birth
Previous Veterinarian
Existing Medical
Conditions
Current
Medications/Dosage
Current Diet
TREATMENT
I, the undersigned owner or agent of the owner, am responsible for seeking veterinary care for
the pet(s) identified above and certify that I am eighteen years or over. I agree that after
consultation with me, the hospital's doctors may prescribe medication to treat, hospitalize,
sedate, anesthetize, or perform surgery on my pet.
Initial______
PAYMENT
I understand that an estimate of the fees for veterinary services will be provided to me at my
request and that I am encouraged to discuss all fees related to it before services are rendered
and during my pet's ongoing medical treatment. I agree to assume financial responsibility for all
fees and will provide payment via cash, credit card, or Care Credit at the time of service.
Initial______
SOCIAL MEDIA
I, hereby grant My Vet Animal Hospital permission to use, reuse, publish, broadcast, in any and
all media my name and the photographs or video footage taken of me and/or my pet in which I
may be included with others. I release My Vet Animal Hospital from any demands arising out of
the use of photographs, video, and audio material including without limitation, all claims for libel
or invasion of privacy.
Initial______
Client Signature:____________________________________________ Date:_____________
AAHA Accredited: We’re Setting the Standard of Veterinary Excellence
"Best Vet," in Chicago Reader's Best of Chicago 2010
info@myvetanimalhospital.com | www.myvetanimalhospital.com