New Client/Patient Information - Paris Road Animal Hospital

Owner's Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you 18 years of age or older? *

Yes
No

Spouse/Co-Owner's Name

First

Last

Spouse/Co-Owner's Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Alternative/Emergency Contact *

First

Last

Alternative/Emergency Contact's Phone *

Pet Information

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Age/Date of Birth *

Breed *

Color/Markings *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Any allergies?

Please list any pre-existing medical conditions

Canine Vaccine History - Please list the date of the previous vaccinations for DA2PL, Bordetella, Rabies, and Canine Influenza *

Feline Vaccine History - Please list the date of the previous vaccinations for FVRCP, FeLV, FIP, and Rabies *

Is your dog on heartworm preventative? *

Yes
No

If yes, what kind? *

Where can pet records be obtained from? *

Phone *

Do you already have a scheduled appointment? Please specify Date and Time.

Date

Time

Do you have an additional pet to add? *

Yes
No

Additional Pet Information

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Age/Date of Birth *

Color/Markings *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Any allergies?

Please list any pre-existing medical conditions

Canine Vaccine History - Please list the date of the previous vaccinations for DA2PL, Bordetella, Rabies, and Canine Influenza *

Feline Vaccine History - Please list the date of the previous vaccinations for FVRCP, FeLV, FIP, and Rabies *

Is your dog on heartworm preventative?

Yes
No

If yes, what kind? *

Agreements

To help prevent the spread of infectious diseases, hospitalized or boarded/daycare animals must be current on all vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS ALL ANIMALS MUST BE CURRENT ON RABIES VACCINATION. Vaccinations can be updated at the time of appointment if the animal is not current.

I understand that payment is due when services are rendered, and that I am fully responsible for that payment at the time of the visit. *

I understand

Do you give permission for any pictures taken during your pet’s stay to be used on o