Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Client Information

Name(Required)

First Last

Spouse or Significant Other’s Name

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Spouse Phone

Email(Required)

Spouse Email

How did you hear about us?(Required)

Individual

Website

Yellow Pages

Other

Someone we may thank?(Required)

Patient Information

Pet’s Name(Required)

Type of Pet(Required)

Dog

Cat

Exotic

Breed(Required)

Sex(Required)

Pet’s Date of Birth(Required)

MM slash DD slash YYYY

Color(Required)

Spayed or Neutered?(Required)

Yes

Previous Veterinary Clinic(Required)

Would you like to have your records transferred to us?(Required)

Yes

Date of your pet’s last vaccinations(Required)

MM slash DD slash YYYY

Date your pet was tested for Heartworms(Required)

MM slash DD slash YYYY

Date your pet was tested for Feline Leukemia/Feline AIDS(Required)

MM slash DD slash YYYY

Date your pet was tested for Fecal(Required)

MM slash DD slash YYYY

Any allergies to vaccinations or medications?(Required)

Yes

Please explain(Required)

Any significant past medical history or surgery(Required)

Do you have any other pets in the house?(Required)

Yes

Please list:(Required)

Pet Insurance Carrier(Required)

(If you don’t have pet insurance and would like information, please ask a staff member)

Professional Fees Are To Be Paid At Time Services Are Rendered

Please select your preferred method of payment(Required)

CASH

CHECK

AMEX

VISA

DISCOVER

CARECREDIT

IF YOU WISH TO PAY BY CHECK, FLORIDA STATUTES REQUIRE PROOF OF IDENTIFICATION

HOSPITAL POLICY

Our hospital policy is to treat your pet as if it were our own by providing your pet with the highest quality veterinary care available. All pets entering the hospital for treatment, grooming or boarding must be current on all recommended vaccinations and be free of parasites. Any parasitic treatment will be done at the owner’s expense.

PAYMENT POLICY

All fees must be paid in full at the time services are performed or upon discharge from the hospital. We accept cash, checks, debit card, Discover, AMEX, MasterCard, and Visa for your convenience. We also accept Care Credit. In some cases, a deposit will be required prior to the onset of treatment or surgery. A service charge of 18% APR ($5.00 min.) is applied to any balance over 30 days. Should it become necessary for the Boca Palms Animal Hospital to collect this account through the use of an attorney, you hereby agree to pay all costs of collection, including a reasonable attorney’s fee, court costs and all expenses associated therewith

PERMISSION TO TREAT

We are happy to provide written estimates prior to the onset of any surgical, treatment or boarding procedures upon the owner’s request. We will also try to contact the owner or duly authorized agent for the owner in the event that additional procedures are recommended while the pet is in our care. I understand that in the event of an emergency, the staff veterinarian will use their best judgement in treatment of your pet including the use of sedatives or anesthetics. I do hereby release Boca Palms Animal Hospital, its agents, employees or representatives from any and all liability while caring for my pet which may include transporting, medical or emergency treatment. Furthermore, I agree to pay fees for services that are rendered at the time the pet is discharged from the clinic or when service is otherwise terminated. I further understand that veterinary service is provided during the nighttime hours as necessary in the judgement of the veterinarian in charge. Continuous presence of qualified personnel may not be provided at all times.

VACCINATION AUTHORIZATION

Vaccination against disease is a medical procedure and, like all medical procedures, carries some inherent risk. As in any medical procedure or decision, the advantages must be balanced against the risks. As is the case with any medical decision, we base the vaccines your pet needs only after considering your pet’s age, lifestyle, and potential exposure to infectious diseases. In general, vaccine reactions and side effects (such as local pain and swelling) are self-limiting. Allergic reactions are less common, but if untreated can be fatal. Our office uses the safest vaccines available to reduce any risks to your pet however, you must be made aware of these potential risks.

PROOF OF OWNERSHIP

I understand that the Boca Palms Animal Hospital reserves the right to look for the presence of a tattoo or microchip in any animal brought in to the clinic. Should either form of identification be found, the Boca Palms Animal Hospital reserves the right to require proof of ownership from the current owner or owner’s agent, or to seek out the rightful owner of said pet.

My signature below acknowledges the fact that I have read and agree to the above information:(Required)

Date(Required)

MM slash DD slash YYYY

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