client/petinformationSheet Owner's Name* Spouse/Other Address* City* State*CaliforniaAlabamaAlaskaArizonaArkansasColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip* Primary Phone*Primary Phone Type Home Cell Work Secondary PhoneSecondary Phone Type Home Cell Work Spouse/Other PrimarySpouse/Other Primary Type Home Cell Work Spouse/Other SecondarySpouse/Other Secondary Type Home Cell Work Email Address* For Pet Desk reminders & hospital communication onlyOwner's Birthdate* MM slash DD slash YYYY Mandatory for CURES reporting in order to dispense certain medicationsEmergency Contact* Phone*How did you find out about Western Vet Group? Referred by Hospital Building/Sign Hospital Website Yelp Search engine Other Referred by (Please let us know who so we can thank them!)Search engineGoogleBingDuck Duck GoDogpileYippyWebopediaYahoo!The Internet ArchiveGoogle ScholarOther Photo & Social Media ReleaseWestern Veterinary Group asks permission use photographs of you and/or your pet with or without your name and for any lawful purpose, including, for example, such purposes as social media posts, publicity, illustration, advertising, and Web content. Please check one of the following: (required)Photo & Social Media Release Types* Yes, you may use photos of me and/or my pet Yes, you may use photos of my pet, but NOT me Please do NOT use photos of myself or my pet Hospital Information (Initial to the left of each item listed below)Western Veterinary Group is not a 24-hour facility and is not staffed overnight. If our doctor(s) feel your pet is not stable & in need of 24 hour care, we may refer you to a trusted local 24-hour facility for continued care.* We have a pharmacy on the premises, and an online pharmacy with Covetrus (vetsfirstchoice.com). Please be advised Western Veterinary Group does not work directly with pharmacies outside of Western Veterinary Group or Vets First Choice. However, if you wish to work with a different pharmacy, we are happy to supply you with a written prescription that you may to take to or mail in to your local or online pharmacy of choice.* Fees are due at the time of services rendered and a deposit is required at the time of drop off for any pet being admitted to the hospital for procedure(s) and/or hospitalization. A written treatment plan will be provided for client authorization prior to services and a copy will gladly be provided to you upon request.* Accepted payment types: Visa, MasterCard, American Express, Discover, CareCredit, Trupanion Express, Scratchpay and Cash. We do NOT accept personal or business checks.* Please read and sign the following authorization: I hereby authorize Western Veterinary Group and its staff to render any treatment deemed necessary to my pet(s) health while in custody of the hospital. I understand that in the event of any unusual or emergency circumstance, the staff will make every attempt to contact me before proceeding with treatment. I understand that veterinary medicine is a practice and that no treatment guarantees a cure or definitive diagnosis. I understand that I will be financially responsible for all services including treatment plans provided to me in person and over the telephone.Client Signature* Date MM slash DD slash YYYY Patient SectionPatient 1 Name* Age or D.O.B.* Species* Canine Feline Other Species (Other) Breed* Sex* Male Female Spayed/Neutered* Yes No Microchip # Color(s) Distinguishing Marks Is this pet insured* Yes No Company Policy # Vaccine/Medical HistoryDoes your pet have history of any of the following? (Please describe)DHPP MM slash DD slash YYYY Bordetella MM slash DD slash YYYY Rabies MM slash DD slash YYYY Influenza MM slash DD slash YYYY Heartworm Test MM slash DD slash YYYY Fecal MM slash DD slash YYYY Blood Test MM slash DD slash YYYY FelineFVRCP MM slash DD slash YYYY Feline Leukemia MM slash DD slash YYYY Rabies MM slash DD slash YYYY FeLV/FIV Test MM slash DD slash YYYY Fecal MM slash DD slash YYYY Blood Test MM slash DD slash YYYY Vaccine Reaction(s)(Please let us know which vaccine(s) and describe the reaction) Does your pet have history of any of the following?(Please describe) Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Previous Veterinarian Hospital May we call for records? Yes No Patient 2 Name Age or D.O.B. Species Canine Feline Other Species (Other) Breed Sex Male Female Spayed/Neutered Yes No Microchip # Color(s) Distinguishing Marks Is this pet insured Yes No Company Policy # Vaccine/Medical HistoryDoes your pet have history of any of the following? (Please describe)Does your pet (2) have history of any of the following?(Please describe) Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Previous Veterinarian Hospital May we call for records? Yes No Patient 3Patient 3 Name Age or D.O.B. Species Canine Feline Other Species (Other) Breed Sex Male Female Spayed/Neutered Yes No Microchip # Color(s) Is this pet insured Yes No Company Policy # Vaccine/Medical HistoryDoes your pet have history of any of the following? (Please describe)Does your pet (3) have history of any of the following?(Please describe) Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Previous Veterinarian Hospital May we call for records? Yes No Patient 4Patient 4 Name Age or D.O.B. Species Canine Feline Other Species (Other) Breed Sex Male Female Spayed/Neutered Yes No Microchip # Color(s) Is this pet insured Yes No Company Policy # Vaccine/Medical HistoryDoes your pet have history of any of the following? (Please describe)Does your pet (4) have history of any of the following?(Please describe) Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Previous Veterinarian Hospital May we call for records? Yes No Patient 5Patient 5 Name Age or D.O.B. Species Canine Feline Other Species (Other) Breed Sex Male Female Spayed/Neutered Yes No Microchip # Color(s) Is this pet insured Yes No Company Policy # Vaccine/Medical HistoryDoes your pet have history of any of the following? (Please describe)DHPP MM slash DD slash YYYY Bordetella MM slash DD slash YYYY Rabies MM slash DD slash YYYY Influenza MM slash DD slash YYYY Heartworm Test MM slash DD slash YYYY Fecal MM slash DD slash YYYY Blood Test MM slash DD slash YYYY FelineFVRCP MM slash DD slash YYYY Feline Leukemia MM slash DD slash YYYY Rabies MM slash DD slash YYYY FeLV/FIV Test MM slash DD slash YYYY Fecal MM slash DD slash YYYY Blood Test MM slash DD slash YYYY Does your pet have history of any of the following?(Please describe) Vaccine Reaction(s) Medical Conditions or Allergies Aggressive/fearful tendencies Vaccine Reaction(s) Aggressive/fearful tendencies Medical Conditions or Allergies Previous Veterinarian Hospital May we call for records? Yes No Appointment Date and Time (if already scheduled):Appointment Date MM slash DD slash YYYY Appointment Time Hours : Minutes AM PM Notice of Abandonment If, after (5) days from the date of written notice, your pet is not picked up it will be considered abandoned and may be adopted out, humanely euthanized, or handled in any manner deemed appropriate by Western Veterinary Group. It is understood that this does not relieve me from paying all of the fees for services, use of hospital, cost of keeping the animal, or collections fees. By signing below I acknowledge I have read and understand the Notice of Abandonment and that I am the owner of the pet(s) listed above.Client Signature Date MM slash DD slash YYYY Western Veterinary Group also offers a variety of additional services such as:Boarding, Bathing, Acupuncture, Cold laser treatment, and more! Please see a Client Service Representative for details.