*Your Name:

*Your Email:

Spouse/Co-owner:

*Your Address:

*City:

*Zip Code:

*Phone:

How Did You Hear About Us?

Patient Information

Pet's Name:

Pet Type:

If other:

Pet's Breed:

Pet Gender:

Spayed/Neutered?

Date of Birth:

Color:

Microchip Number:

AKC Registered Name:

Pet's Name:

Pet Type:

If other:

Pet's Breed:

Pet Gender:

Spayed/Neutered?

Date of Birth:

Color:

Microchip Number:

Would you like us to obtain your pet’s medical record from another veterinarian to update our records?

Financial, Medical information and Liability Release
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety issues in hospital care and handling. I hereby authorize applewood Animal Hospital to receive, prescribe for, treat and/or perform surgery upon the pet(s) listed herein and additional pets I present. I understand that no guarantees have been made as to the results of medical and/or surgical treatment. I agree to release Applewood Animal Hospital and its staff from any liability resulting from the treatment, surgery and/or hospitalization of my animal(s). I certify that I am over 18 years of age and am the owner or owner’s authorized agent of animals identified on the Patient Information Form. I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I assume full responsibility for all charges incurred in the treatment of my pets. I agree that in the event that any unpaid balance is referred to a collection agency, I will be responsible for all collection fees, legal fees and court costs and your owed balance may substantially increase.
I Agree