& Print Form - Kowaliga Whole Health Pet Care

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KOWALIGA WHOLE HEALTH PET CARE & RESORT
Dr. Mary S. Battistella, DVM
8610 Kowaliga Road
Eclectic, AL 36024
(334) 857-1816
___________________________________________________________________
PATIENT/CLIENT INFORMATION
FULL NAME ________________________________________________________________________________
ADDRESS __________________________________________________________________________________
CITY _____________________________________ STATE _______________ ZIP ________________________
E-MAIL ___________________________________________________________________________________
HOME PHONE # ____________________________________________________________________________
CELL PHONE # _____________________________________________________________________________
WORK PHONE # ____________________________________________________________________________
EMPLOYER ________________________________________________________________________________
SPOUSE'S NAME ___________________________________________________________________________
SPOUSE'S CELL PHONE # _____________________________________________________________________
In addition to phone calls and postal mail, we also like to communicate with our clients via e-mail. Please
provide us with your e-mail address so we may send you important health information regarding your pet. Be
confident that we will keep your e-mail address private, just as we do the rest of your account.
How did you become aware of our hospital? ________________________________________
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. BY SIGNING, I AGREE THE ABOVE
INFORMATION IS CORRECT AND IS A LEGAL AND LAWFUL DEBT. SHOULD IT BECOME NECESSARY TO
FORWARD THE ACCOUNT FOR COLLECTION, I AGREE TO BE RESPONSIBLE FOR ANY/ALL COLLECTION COSTS,
ATTORNEY FEES, AND/OR COURT COSTS. I WAIVE NOW AND FOREVER MY RIGHT OF EXEMPTION UNDER
THE LAWS OF THE CONSTITUTION OF THE STATE OF ALABAMA AND ANY OTHER STATE.
DATE _______________________________
SIGNATURE OF OWNER _________________________________________________________
Please bring this form with you for your first visit to our clinic. Please answer all
questions to the best of your ability. We look forward to serving you and your pet(s).
PET’S INFORMATION
Pet’s Name
Species
Breed
Color
Date of Birth
Age
Sex
Spayed or Neutered?
Length of Time Owned
Vitamins
Diet (kind of pet food)
Grooming Products Used
Flea Prevention Used
Heartworm Prevention
Used
Name of Former Clinic
Number of
Former Clinic
Last Rabies Vaccination
Last Fecal Exam
Last Parvovirus Vaccine
(DOGS ONLY)
Last Distemper/DHLP
Vaccine (DOGS ONLY)
Last Bordetella
(DOGS ONLY)
Last Heartworm Test
Last Leukemia Vaccine
(CATS ONLY)
Last FVRCP
(CATS ONLY)
Prior Illness’
Prior Surgeries
Last Dental Cleaning
Allergies?
PET #1
PET #2
PET #3
Pet #4
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