"*" indicates required fields Client-Patient Information Form 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 MM slash DD slash YYYY Owner's Name* First Last Co-Owner's Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Phone Number*Co-Owner's Contact NumberWork Phone NumberCo-Owner's Work NumberEmail* Driver's License No.EmployerCo-Owner's EmployerPreferred Method of Contact* Cell Phone Home Phone Work Phone Email 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?*If Another Business,*Pet Information #1Name*Species* Feline (cat) Canine (dog) Exotic Breed (type)*Color*DOB / Age*Sex* Male Intact Male Neutered Female Intact Female Spayed Prior IllnessPrior surgery not including alteringDate of last Vaccines & Clinic done atVaccineDateClinic Add RemovePet Insurance CompanyPet Information #2NameSpecies Feline (cat) Canine (dog) Exotic Breed (type)ColorDOB / AgeSex Male Intact Male Neutered Female Intact Female Spayed Prior IllnessPrior surgery not including alteringDate of last Vaccines & Clinic done atVaccineDateClinic Add RemovePet Insurance CompanyPet Information #3NameSpecies Feline (cat) Canine (dog) Exotic Breed (type)ColorDOB / AgeSex Male Intact Male Neutered Female Intact Female Spayed Prior IllnessPrior surgery not including alteringDate of last Vaccines & Clinic done atVaccineDateClinic Add RemovePet Insurance CompanyNotification/AgreementTo 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 recordsI authorize the Woodland Veterinary Center to acquire 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 AgreementWoodland Veterinary Center is committed to providing all 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 CONSENTI 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.* 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 in to 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 the Woodland Veterinary Center, 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. Print Name*Date* MM slash DD slash YYYY Signature* Reset signature Signature locked. Reset to sign again NameThis field is for validation purposes and should be left unchanged.
