"*" indicates required fields Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell #*Home #Work #Email* Drivers' License*Occupation / Employer*How did you hear about our office?*Co-OwnerName First Last Cell #Work #Email County Line Animal Hospital requires payment in full at the end of your pet's examination and/or at the time of discharge. When extensive care is needed a 50% deposit may be required prior to starting treatment. Payment Options: Cash, Debit, Visa®, MasterCard®, American Express® ,Discover Card® and Apple Pay Convenient Monthly Payment Options¹ from the CareCredit® Healthcare CreditCard (Upon Approval) Allow you to begin treatment today and pay over time Available for any treatment amount **AN ESTIMATE FOR SERVICES WILL BE GIVEN UPON REQUEST ONLY** I hereby acknowledge that the above information is true and correct. I acknowledge that I am 18 years or older and the legal owner or authorized representative of the legal owner, and that I am authorized to make decisions regarding my pets medical care. I acknowledge that I am legally responsible for all financial care of my pet/s Signature*Date* MM slash DD slash YYYY Pet InformationPet's Name*Species* Canine Feline Gender* Male Female Spayed / Neutered* Yes No Unknown Breed*Color / Markings*Birthdate (or approximate age if unknown)*Does your pet have a microchip?* Yes No ID#*Does this pet have pet insurance?* Yes No Insurance Carrier*Medical HistoryHas your pet ever had a reaction to vaccines?* Yes No If yes, please explain*Does your pet have any known allergies?* Yes No If yes, please explain*Is your pet current on vaccines?* Yes No Please list*Has your pet had a Fecal Parasite check performed within the last year?* Yes No Has your pet had a Heartworm test performed within the last year?* Yes No Does your dog have any major medical history or past surgeries?*Is your dog currently on any medications, supplements or flea/tick medication?* Yes No If yes, please list:*Lifestyle / BehaviorHas your dog or cat ever bitten a person?* Yes No Is your dog friendly with other dogs?* Yes No Most of the time What food are you currently feeding?*May we contact your previous vet for records?* Yes No If yes, please let us know who to contact*We love taking pictures of our patients! Please let us know if we can share pictures of your fur baby!I grant to County Line Animal Hospital , its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that County Line Animal Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. The above may take photos of me and/or my pet The above may NOT take photos of me and/or my pet Please tell us the reason for your pets visit with us todaypast health history and vaccination records Drop files here or Select files Max. file size: 256 MB. Signature*Date* MM slash DD slash YYYY
