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Your Name

Please list your full name.

Appointment Date

What day is your scheduled appointment?

Address

Please list your current mailing address so we may verify our records.

City

State

Zip Code

Email

Please list your current email address so we may verify our records.

Phone

What is the best phone number to reach you today?

Pet's Name

If you are dropping off more than one pet, please compete a separate form for each pet.

Are you the primary owner for this pet?

A primary owner is the main contact, makes medical decisions, and is financially responsible for this pet.

Yes
No

Other Primary Owner

Please list the primary owner for this pet.

Primary Phone

Please list all contact numbers for the primary owner of this pet.

Secondary Owner

Please list a secondary owner if there is one for this pet. A secondary owner can authorize medical treatments and make financial decisions on your behalf. The primary owner is responsible for any financial decisions made by the secondary owner.

Secondary Phone

Please list all contact numbers for the secondary owner of this pet, if applicable.

Preferred Contact Method

Which contact method do you prefer for an update on when your pet is ready to go?

Call me on my phone.
Text me on my phone.
Other

Other

Please describe.

Appointment Type

Please list the reason for your pet's visit today.

Additional Services

Please select the services you would like your pet to have during this appointment.

Other Service(s): Describe

Feeding

Please list your pet's brand of food and if you feed dry/wet/combination of both.

Servings

Please select what best describes the normal amount of food fed to your pet and how often they are fed.

My pet grazes throughout the day.
My pet eats a measured amount of food each day.
I feed my pet once a day.
I feed my pet twice a day.
My pet has free choice and I refill the bowl when empty.
Other

Servings: Other

Please describe.

Environment

Please select all that represents your pet's normal environmental exposure.

My pet lives inside my home.
My pet lives outside.
I have a fenced-in yard for my pet to explore freely.
I leash-walk my dog to the restroom.
My pet is allowed to explore the outdoors freely.
My cat is allowed to explore on a screened-in porch or enclosure.
Other

Environment: Other

Please describe.

Medications

What medications are your currently giving your pet?

Medications: Other

Please describe.

Medication(s) Brand

Please list the brand(s) of the medication(s) you are giving your pet.

Medication Refill

Do you need any refills on your pet's medications?

Yes
No

Refill Request

Please list what medication(s) you need to be refilled and the quantity.

Tests Authorization

When performing the physical exam, the veterinarian may order tests to better diagnose your pet's medical issues. Please check any tests that you agree to be performed without a phone call for an authorization.

Doctor Preference

Our veterinarians can be requested. If they are working and available on your appointment date, you may list a request.

I request Dr. Debbie Edwards if available.
I request Dr. Justin Card if available.
I do not have a preference.

Care Authorization

By checking this box, I authorize the veterinarians and staff at Best Friends Animal Hospital to perform the elected procedures. I accept that all procedures will be performed to the best of the ability of all employees at this hospital and I understand that no guarantee or warranty has been made regarding the results that may be achieved. I have read and fully understand the terms and conditions.

I agree

CPR Authorization

In case of an emergency, please choose from the following options how you would like for us to proceed with CPR. The veterinarian and staff will make every effort to contact you as soon as possible.

I authorize the veterinarian and staff to begin full CPR efforts without my verbal consent.
I authorize the veterinarian and staff to begin minimum CPR efforts without my verbal consent.
I do not authorize the veterinarian to begin any CPR without my verbal consent. I understand that waiting for my consent may cause the veterinarian to be unable to resuscitate my pet.

Financial Disclosure

If you have any financial concerns about payment for your pet's medical treatments or medications, please let a receptionist know before leaving your pet. We offer Care Credit and iCare. We do not offer in-house financing.

Financial Responsibility

By checking this box, I agree that I am the primary owner of this animal and I am financially responsible for all charges on this pet's account, or I have authorization from the primary owner to take these responsibilities. I understand that payment is due when I pick up my pet.

I agree