Client InformationName* First Last Date* Date Format: MM slash DD slash YYYY Spouse/Partner Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Reason for Visit:*How did you hear about our practice?*Friend/NeighborFacebookNewspaperWebTVDMVDrive ByWho can we thank?*Pet InformationPet's Name*Type of Animal*CanineFelineOtherPlease specify*Breed*Sex*MaleNeuteredFemaleSpayedColor*Date of Birth* Date Format: MM slash DD slash YYYY Weight*Microchip*Has this pet been examined by a veterinarian within the past year?*YesNoUp to date on all vaccines?*YesNoHas this pet bitten anyone in the last 10 days?*YesNoPlease check any symptoms or problems that you have noticed about your pet* Behavior Problems Bleeding Gums Breathing Problems Coughing Diarrhea Eye Bulging or Bloodshot Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Thirst and/or Urination Increased Vomiting Weakness Weight Problem Other None of the above Other: please specify*Current medications if any:*Describe your pet's Diet*Prior Illness/Injury/Surgery*Allergies to Medicine/Vaccines*Authorization* I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. Method of payment*Credit CardCheckCashCare CreditDate* Date Format: MM slash DD slash YYYY Signature of owner/or acting as agent for the owner*HIPPA Release* I authorize Taconic rt202 24 Hour Veterinary Center, to release information including diagnosis, records, labwork and x-rays of my above named pet. This information may be released to:* Emergency Veterinary Hospitals Referral Specialists Insurance Company Other Information is not to be released to anyone Name of Insurance Co:*Policy #:*Other: please specify** This release information will remain in effect until terminated by me in writing Date* Date Format: MM slash DD slash YYYY Signature*
