CARDIFF ANIMAL  HOSPITAL, INC.

CLIENT INFORMATION

OWNER'S LAST NAME_______________________________________ FIRST_________________________________

ADDRESS______________________________________________CITY_____________________________ZIP__________

HOME PHONE:(_____)__________________________WORK PHONE:(_____)___________________________________

EMPLOYER________________________________________ CELL PHONE (_____)_______________________________

SPOUSE/OTHER_______________________________________ SPOUSE/ALTERNATE PHONE ___________________

DRIVER’S LICENSE #______________________________ DATE OF BIRTH:_________Req’d for dispensed controlled drugs.

REFERRED BY:  PERSON:_____________________________________YELLOW PAGES:______ INTERNET:________

        BUSINESS SIGN:______SHELTER (WHICH ONE?):_____________________OTHER:________________________

IN CASE OF EMERGENCY, PLEASE CALL_____________________________________AT_______________________

PLEASE NOTE THE FOLLOWING FEE SCHEDULE:

                All fees are to be paid when services are rendered.  A deposit is required on all hospitalized pets and the balance is due when your pet is released from the hospital.  We accept cash and all major credit cards from first time clients.   Outstanding balances may be turned over to a collection agency and you will be liable for interest, service charges and legal fees.

SIGNATURE_____________________________________________________________DATE_____________________

PET INFORMATION

PET'S NAME:___________________________________________________________________________

SPECIES:  DOG:______CAT:______ OTHER:_____________________________________

SEX:                    MALE____   FEMALE____                         SPAYED/NEUTERED:            YES____   NO____

DATE OF BIRTH:______________________ BREED:_________________________ COLOR:___________________

NAME OF PREVIOUS VETERINARY HOSPITAL ____________________________________________________

ANY KNOWN ALLERGIES?_________________________________________________________

ANY KNOWN VACCINE REACTIONS?_____________________________________________

 FOOD  (BRAND NAME):________________________________________________________

IS YOUR PET MICROCHIPPED?__________  MICROCHIP BRAND & NUMBER:________________________________

FELINES ONLY: INDOOR ONLY______ OUTDOOR ONLY______ INDOOR/OUTDOOR______