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					                            PATIENT AND CLIENT INFORMATION SHEET

Thank you for choosing Platte Woods Animal Hospital for your pet’s health care needs. Please be assured
we will provide your pet with top level medical care in a compassionate environment.

Owner                                                  Spouse/Other

Address                                        City                       State            Zip

Telephone (H)                         e-mail
          (W)

Employer’s Name                                Spouse/Other Employer
                                               Spouse/Other Telephone #

Drivers license/ SSN                                                      Birthdate__________________
Emergency contact Name and Phone #

Pet Information                            Pet 1               Pet 2                    Pet 3

Name

Species (Feline/Canine)

Breed

Date of Birth

Description (i.e. color)

Sex (spayed or neutered)

Date of last vaccine
         DHPP/FVCRP
         RABIES
         BORDATELLA

Date/result of last Heartworm test

Date of last FelK/FIV test (result)

Prior Medical Conditions


How did you first hear of our hospital?
Individual                          Someone we may thank?
Yellow Pages               AHAA referral
Hospital Sign              Other (please specify)

*To prevent the spread of infectious disease and parasites, hospitalized and boarded animals must be
current on all vaccines and free of internal and external parasites. I authorize the doctors to vaccinate and
use parasite control as needed for my pets.
*We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor for one. Fees
are due at the time services are rendered. We accept cash, check, Mastercard, Visa, Discover, and Den
Charge and Veterinary Pet Insurance for payments.

Owner Signature
Date

				
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posted:12/20/2010
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