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Phone:
(334) 277-1101
| Monday - Friday: 7:00 AM - 6 PM | Saturday: 8 AM - 12 PM
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(334) 277-1101
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Client and Contact
First and Last Name
Address
*
Street Address
Address Line 2
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ZIP / Postal Code
Home Phone
*
Cell Phone
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Email
*
How did you become aware of this clinic?
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*
Hospital Sign
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If other, please specify
Emergency Contact Person
*
Home Phone
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Name of Previous Veterinarian
Phone of Previous Veterinarian
Pet Information
Pet 1
Pet 1 Name
*
Sex
*
Species
*
Canine
Feline
Exotic
Avian
Reptile
Breed
*
Color
*
Pet Age
*
Pet 2 (optional)
Pet 2 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
Pet Age
Pet 3 (optional)
Pet 3 Name
Sex
Species
Canine
Feline
Exotic
Avian
Reptile
Breed
Color
Pet Age
Our Fee Policy
*
I understand that all fees are due at time of service. If you are in need of alternative payment arrangements please discuss that prior to completion of services.*
Yes, I understand the fee policy.
Consent
*
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.
Photo Release: I agree that East Montgomery Animal Hospital may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites. I have read the above statement and by submitting this form, I understand and agree to the conditions above.*
Accept
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