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Please print this form, fill it out and bring it with you to your appointment.
Home Phone______________________________
Owner's Name __________________________ Co-owner's Name__________________________
Owner's Address____________________________________________ Zip Code_____________
Work Phone__________________________ Co-owner's Work Phone_______________________
Cellular/Pager_________________________ Co-owner's Cellular/Pager______________________
Employer_____________________________ Co-owner's Employer__________________________
In case of emergency call:___________________________ at____________________
How did you first hear of us? (Please circle one) | | | | | | | | | | q Check here if any owner qualifies for our Senior Citizen 10% Discount (65 years or older).
F- Friend/Client    Whom may we thank? _________________________________________________ Is any household member elderly or Immuno-suppressed?  qYes   qNo
N -Newspaper/Magazine    Which one? ___________________ Number of household pets: ___________Cats
P -Professional Referral   Who? _________________________   ___________Dogs
I -Impact Yellow Pages  R -Regional Yellow Pages A -Radio M -Mailer   ___________Other:
U -US West Yellow Pages T -TV Describe:____________________________________ ____________________________________________
S -Sign/Location   W-Web Search
Cat's Name: __________________________ Birth Date or Approximate Age____________
Breed: q Domestic Short Hair q Domestic Medium Hair q Domestic Long Hair q Other: __________
Color____________________ q Female q Spayed Female q Male q Neutered Male
Abnormalities, previous problems, drug/vaccine reactions:_________________________ ________________________________________________________________________
Leukemia tested? q Yes q No   Results:_____________ Date:___________
AIDS tested? q Yes q No  Results:_______________ Date:___________
Date of last FVRCP vaccine?____________       Date of last FelV vaccine?_____________
Date of last FIP vaccine?_____________   Date of last Rabies vaccine?___________
Was the Rabies vaccine good for q 1 year or  q 3 years?
Declawed? q Yes   q No Go outside? q Occasionally q Never q A lot
How long have you had this cat?__________ Where did you get this cat?_______________
  OUR FINANCIAL POLICY
q We expect full payment at the time of service/discharge unless PRIOR arrangements have been made.
q We accept cash, check, Visa/Mastercard, Discover, American Express, and debit cards.
q All checks are run electronically through TeleCheck.
q A deposit of 25-50% may be required before extensive services are performed.
q For cats brought in by unaccompanied minors, non-emergency treatment will be denied unless payment arrangements have been pre-authorized and arranged with our staff.
q Pick-ups by non-owners must be pre-authorized and payment arrangements made in advance-
q Missed appointments are expensive; time and staff have been arranged just for you. If you find you cannot keep your appointment, please let us know as soon as possible.
 I have read, understand, and agree to the above Financial Policy.

 Owner/ Responsible Party_________________________________ Date____________

 Co-owner/ Responsible Party_________________________________ Date____________