Thank you for the opportunity to care for your pet(s). Please complete the following information so that we may better serve you. Owner InformationName Spouse / Additional Owner Name Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail How did you become aware of our clinic? Internet Drive By / Sign Direct Mailer Referral Whom may we thank? I acknowledge that I am the owner or acting upon direct request of the owner of the pet(s) brought into this facility. Furthermore, I accept all financial responsibility for any and all care rendered while at this facility and understand that payment is due in full at the time that services are provided. Patient Information Dog Cat Name Breed Color Birth Date SexMFSpayed / NeuteredYesNoMicrochipped?YesNoPrevious Illnesses / SurgeriesPrevious / Known Allergies to Vaccinations or MedicationsRabies Dist / Parvo Bordetella HWT Fecal May we take a picture of your pet? We would love to show off your pet to our Facebook followers and around the clinic. Allowing us to take pictures not only allows us to educate pet owners, it also allows us to keep a visual record of your pet should they get lost. By initialing you are authorizing Chalco Hills Animal Hospital and its employees to use pictures of you / your pet as they see fit (I.E.: Published articles, internet, and professional settings). Please initial one option. The above may take pictures of me and/or my pet The above may NOT take pictures of me and/or my pet.