Welcome to Platte Woods Animal Hospital
Thank you for giving us this opportunity to care for your pet. Please help us meet your needs better by completing the following information. If you have any questions, do not hesitate to ask a receptionist for assistance.
INFORMATION ABOUT YOU
Your Name: Mr. Mrs. Miss Ms. Dr
______________________________________________________________________________________________
Spouse/Other:
_______________________________________________________________________________________________
Address: City, State, Zip
______________________________________________________________________________
Residence Phone Work Phone:
________________________________________ ________________________________
Cell Phone/Other E-Mail- Permission to send reminders/newsletters? ❏ Yes ❏ No
_______________________________________ ______________________________________________
Employer:
______________________________________________
Spouse/Other’s Employer
_________________________________ ____________
Driver’s License #: ____________________________________ State:____________(needed if paying with Check)
In case of Emergency, Contact and Phone Number:
_____________________________ _______________________________________________
How did you first hear of us?
❏ Website ❏ AAHA referral
❏ Yellow Pages ❏ Drove by/Clinic sign
❏ Individual recommendation by: ____________________________________________
❏ Other: ________________________________________________________________
INFORMATION ABOUT YOUR PET
Pet’s name: _________________________ ❏ Dog ❏ Cat ❏ Other: _________________
Breed:__________________ __Color: ___________ ______ Sex: ❏ M ❏ F Spayed? ❏ Yes ❏ No
Date of birth (approximately): _________________________ Neutered? ❏ Yes ❏ No
Previous Veterinarian (if any): ______________________________________ Phone (if known): ______________________
Past Medical Issues____________________________________________________________________________________
When was your pet last vaccinated (approximately)?
Dogs: Rabies: _________________________ ❏ 1-year ❏ 3-year Distemper Parvo: ____________________________
Bordetella: ______________________
Cats: Rabies: _________________________ ❏ 1-year ❏ 3-year FVRCP: _____________________
Feline leukemia: __________________
Second Pet’s name: _____________________ ❏ Dog ❏ Cat ❏ Other: _________________
Breed:_____________________ Color:______ ___________ Sex: ❏ M ❏ F Spayed? ❏ Yes ❏ No
Date of birth (approximately): _________________________ Neutered? ❏ Yes ❏ No
Past Medical Issues____________________________________________________________________________________
When was your pet last vaccinated (approximately)?
Dogs: Rabies: _________________________ ❏ 1-year ❏ 3-year
Distemper Parvo: ________________________ Bordetella: ______________________
Cats: Rabies: _________________________ ❏ 1-year ❏ 3-year
FVRCP: _____________________ Feline leukemia: __________________
Reason for today’s visit: __________________________________________________________________________
*Professional fees are due at the time services are rendered. We accept cash, checks, Visa, MasterCard, and Care Credit. We will be happy to provide a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization will be provided. A deposit prior to treatment may be required. Thank you for entrusting us with your pet’s care.
*To prevent the spread of infectious disease and parasites, hospitalized/boarding/groom patients must be current on all vaccinations and free of internal and external parasites. I authorize the doctors to vaccinate and use parasite control as needed for my pets
Owners Signature Date