Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a few moments to complete each of the information sheets.

Date

Owner’s Name(Required)

First Last

Co-Owner’s Name

First Last

Address

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

Contact Phone Number(Required)

Co-Owner’s Contact Number

Work Phone Number(Required)

Co-Owner’s Work Number

E-Mail Address(Required)

Driver’s License No

Employer(Required)

Co-Owner’s Employer

Preferred Method of Contact:

Cell Phone

Home Phone

Work Phone

Text

How did you first hear of our hospital?

Personal Recommendation

Our Website

Drove by/ Sign

Previous Client

Google

Facebook

Yelp

Another Business:

Other:

Whom may we thank?(Required)

Which other business?(Required)

Other:(Required)

Animal Information/Medical History for Pet #1

Name(Required)

Species(Required)

Feline (cat)

Canine (dog)

Exotic

Date of Birth(Required)

Breed (type)(Required)

Color(Required)

Sex(Required)

Male Intact

Female Intact

Male Neutered

Female Spayed

Prior Illness

Prior surgery not including altering

Date of last Vaccines & Clinic done at

Pet Insurance Company

Animal Information/Medical History for Pet #2

Name

Species

Feline (cat)

Canine (dog)

Exotic

Date of Birth

Breed (type)

Color

Sex

Male Intact

Female Intact

Male Neutered

Female Spayed

Prior Illness

Prior surgery not including altering

Date of last Vaccines & Clinic done at

Pet Insurance Company

Animal Information/Medical History for Pet #3

Name

Species

Feline (cat)

Canine (dog)

Exotic

Date of Birth

Breed (type)

Color

Sex

Male Intact

Female Intact

Male Neutered

Female Spayed

Prior Illness

Prior surgery not including altering

Date of last Vaccines & Clinic done at

Pet Insurance Company

Notification/ Agreement

To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the Woodland Veterinary Center to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify Woodland Veterinary Center in writing on the contrary.

Authorization for Release of Medical Records

I authorize the Woodland Veterinary Center to acquire any and all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them.

Appointment Cancellation/ Late & Reschedule Policy Agreement

Woodland Veterinary Center is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen.

If you need to reschedule an appointment, please give our office a call at 219-879-0249 the day prior to your scheduled appointment to notify us of any changes or cancellations. If after 2 missed/canceled appointments, you will be charged a deposit before scheduling another appointment. If you miss/cancel that appointment your deposit will be forfeited and another deposit will be required to schedule another appointment.

If you are more than 10 minutes late to your scheduled appointment you may be asked to reschedule the appointment, or you will be seen as a work-in (work in can mean anytime from your original appointment to the time we close) and be charged a work-in fee.

PHOTO CONSENT

I grant to Woodland Veterinary Center, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that Woodland Veterinary Center 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.(Required)

I GIVE permission to the Woodland Veterinary Center to use photos of me and or my pet

I DO NOT permission to the Woodland Veterinary Center to use photos of me and or my pet

PAYMENT INFORMATION

Payment is due in full at the time services are rendered
This office does NOT do any billing, we do NOT offer payment plans
A service charge of 3% will be applied to all card purchases

We accept the following forms of payment:

Visa
MasterCard
Discover
American Express
Care Credit
Cash
Scratchpay
All Pet Card

We accept personal checks with a valid Driver’s License or Social Security Number. There is a $25 fee for all returned checks.

Please print and sign below that you are taking responsibility for full payment of treatment and services for the pets you are bringing into Woodland Veterinary Center, at the time they are treated. If you are not the individual who is financially responsible for these pets, by signing this form you are stating that you have made prior arrangements with the individual who is. I agree to absolve, veterinarian, and staff employed by the practice of any financial consequences that may occur between you and the other individual you have made prior arrangements with.

Name(Required)

First Last

Signature(Required)

Date(Required)

Client-Patient Information Form

Animal Information/Medical History for Pet #1

Animal Information/Medical History for Pet #2

Animal Information/Medical History for Pet #3

Notification/ Agreement

Authorization for Release of Medical Records

Appointment Cancellation/ Late & Reschedule Policy Agreement

PHOTO CONSENT

PAYMENT INFORMATION

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Client-Patient Information Form

Animal Information/Medical History for Pet #1

Animal Information/Medical History for Pet #2

Animal Information/Medical History for Pet #3

Notification/ Agreement

Authorization for Release of Medical Records

Appointment Cancellation/ Late & Reschedule Policy Agreement

PHOTO CONSENT

PAYMENT INFORMATION

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