New Client

Thank you for choosing our hospital to care for your pet. To help us better understand and meet your needs, please take a moment to complete the following information.

Owner Information

Owner Name (required)

Owner Date of Birth (required for pharmacy medication)

Spouse/Significant Other Name

How did you hear about us?
Client
Internet
Sign
Other

Pet Information

Pet Type
Canine (dog)
Feline (cat)

Pet sex
Male
Female

Spayed/Neutered?

Yes

Pet date of birth Enter approximate date if exact date of birth is unknown.

I grant permission to Brentwood Country Animal Hospital to share my pet’s photos online
Yes
No

Contact Information

(For pharmacy, reminders & Hospital communications)

Mailing Address

My home address is the same as my mailing address (required)
Yes
No

Best phone number(s) to reach you

Phone Number	Phone Type	Extension	I can receive texts at this number
			Yes No
			Yes No
			Yes No

Spouse phone number

Phone Number	Phone Type	Extension	Spouse can receive texts at this number
			Yes No

Emergency contact

Name (required)	Address (required)	City (required)	State (required)	Phone (required)

How would you prefer to receive your pet's reminders?
Email
Postcard
Text

Employment & Insurance

Do you have pet insurance? (required)
Yes
No

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.

Cancellations Policy

In consideration of our other patients and staff, if you need to cancel or reschedule your appointment for any reason, we ask that you call the office at least 24 hours in advance, or you account will be charged a $50.00 fee with 3% accrued interest after 30 days

Date signed (required)