Thank you for giving our hospital the opportunity to care for your pet. So that we may be better able to meet your needs, please complete the following. You must have JavaScript enabled to use this form. Owner Information Client Name Please enter the name of the client who referred you to BCAH. Owner Name First Name Middle Initial Last Name Owner Date of Birth (required for pharmacy medication) Spouse/Significant Other Name First Name Middle Initial Last Name How did you hear about us? Client Internet Sign Other Enter other… Pet Information Pet Name Pet Type Canine (dog) Feline (cat) Pet sex Male Female Spayed/neutered? Pet breed Pet date of birth Enter approximate date if exact date of birth is unknown. Pet color I grant permission to Brentwood Country Animal Hospital to share my pet’s photos online Yes No Contact Information Email address (For pharmacy, reminders & Hospital communications) Mailing Address Address 1 Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code My home address is the same as my mailing address Yes No Home address (if different from mailing address) Address 1 Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Best phone number(s) to reach you Phone Number Phone Type Extension I can receive texts at this number Phone Number Phone Type Phone Type - None -CellHomeOfficeOther… Enter other… Extension I can receive texts at this number Phone Number Phone Type Phone Type - None -CellHomeOfficeOther… Enter other… Extension I can receive texts at this number Phone Number Phone Type Phone Type - None -CellHomeOfficeOther… Enter other… Extension I can receive texts at this number Spouse phone number Phone Number Phone Type Extension Spouse can receive texts at this number Phone Number Phone Type Phone Type - None -CellHomeOfficeOther… Enter other… Extension Spouse can receive texts at this number Emergency contact Name Address City State Phone Name Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Phone How would you prefer to receive your pet's reminders? Email Postcard Text Employment & Insurance Place of employment Spouse's place of employment Do you have pet insurance? Yes No Pet Insurance Company Pet Insurance Policy Number Clinic Policies Brentwood Country Animal Hospital strives to maintain high standards in medicine, surgery, cleanliness, and disease prevention. Please be advised of the following requirements: Boarding & Hospitalization Policy All animal admitted to the hospital must be up-to-date on vaccines and dogs undergoing anesthetic procedures need to be tested for heartworm disease. Animals with fleas and/or ticks will be treated at the owner’s expense in order to prevent infestation of our kennel. Financial Policy All fees are to be paid upon completion of treatment and services. Returned check fee $35. 1.5% interest accrues on unpaid balances over 30 days, plus collection costs if necessary. AS LEGAL OWNER OF THIS ANIMAL, I HAVE READ AND AGREE WITH THE ABOVE POLICIES. I WILL NOT HOLD BRENTWOOD COUNTRY ANIMAL HOSPITAL RESPONSIBLE FOR PROBLEMS THAT ARE THE RESULT OF CIRCUMSTANCES BEYOND THEIR CONTROL. Enter your name as your signature Date signed
