Welcome to McPhillips Animal Hospital!

Date

Client Information

Primary Caregiver

Secondary Caregiver

Name*

First Last

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Relationship to Primary Caregiver

Phone*

Cell Number*

Work Number

Place Of Employment

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Please note that your email address is collected only to use in communications from our hospital, we do not share your email address with any third parties.

How did you find out about McPhillips Animal Hospital?

If Other, please specify:

If you have been referred by a friend/relative, we would like to thank them, please supply their contact information below.

ALL FEES ARE DUE AT TIME OF SERVICES RENDERED

We accept CASH, DEBIT, VISA, MASTERCARD, AMEX We do not accept cheques.

NOTE: TO PREVENT THE SPREAD OF INFECTIOUS DISEASES, ALL HOSPITALIZED PATIENTS MUST BE CURRENT ON ALL VACCINES AND FREE FROM INTERNAL AND EXTERNAL PARASITES. THE SIGNATURE BELOW AUTHORIZES THIS LEVEL OF PREVENTATIVE CARE AND THE APPROPRIATE CHARGES WILL BE ASSESSED IN THE DISCHARGE INVOICE.

Patient Information

Pet 1 Name*

Pet 2 Name*

Pet 3 Name*

Breed (if known)

Date of Birth or Age (if known)

Color

Sex

Has your animal been previously vaccinated?

Yes
No

If Yes, when was the last vaccine given: Rabies:

Distemper:

Other:

Would you like a reminder for vaccinations?

Yes
No

Where did you obtain this pet?

Friend
Breeder
Pet Shop
Humane Society

For what purpose was this pet obtained?

Companion
Protection
Breeding
Show

Other