Client & Patient Information Form Angel Animal Hospital 24307 Halsted Farmington Hills Mi, 48335 Owner Information: (must be completed in full) First* Last* Address* City* State* Zip* Home Phone* Cell Phone* Driver’s License #* Would you like email reminders?* YesNo Email (for reminders only) How did you hear about our office? Referred by: Employer Work # Pet Information: (must be completed in full) Name * Sex* * MaleFemale Neutered/Spayed:* * YesNo Species* * DogCatOther If cat IndoorOutdoorBoth Breed* Color/Markings* Birth Date/Approximate Age* Microchip ID#* Are you interested in a Microchip?* * YesNo Previous/Current Vet* Is your pet current on Vaccines/ Heartworm test/ and Fecal test?* Medical History (please list any conditions, allergies, medications, vaccine history, etc.)* I, the undersigned, do hereby certify that I am the owners (or duly authorized agent for the owner) of the animal described above and of 18 years of age or older. I understand that every effort will be made to be achieve a successful outcome, and to provide for all the possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe, treat, or perform surgery upon the pets on file and any additional pet I present. Furthermore, I agree to pay these fees in full for the services rendered at the time the pet is admitted to the hospital. Accounts not paid within terms are subject to a 1.5% monthly finance charge. I understand that veterinary service is not provided during the nighttime hours. If I neglect to pick up my pet within three (3) days of discharge date agreed upon and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to dispose of the pet as you deem best or necessary. Signature* Date* * Required field.
