Owner: _________________________________________________________________________________________________________

First Name                                 Last Name

Pet’s Name:______________________________________        Species (Circle One):          Cat             Dog

Breed: ____________________________ Color: _____________________  Approx. Age or Date of Birth:___________________________

Sex (Circle One):           Female             Male                   Circle if Applicable:              Spayed               Neutered            

Microchip Number: ________________________________________________________________________________________________

Where/When did you acquire your pet?_________________________________________________________________________________

Medical History

What do you feed your pet?__________________________________________________________________________________________

Does your pet have any ongoing medical conditions? _____________________________________________________________________

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Please list your pet’s current medication(s) _____________________________________________________________________________

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Has your pet had any surgeries (besides spay/neuter) or dental work (specify type and dates)_____________________________________

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Does your pet have any allergies to vaccinations, medications, food, fleas, etc.? ________________________________________________

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Are there any special considerations regarding your pet (Dog reactive, prefers female staff/handlers, etc)? ___________________________

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I understand that I am at least 18 years of age and financially responsible, for all charges incurred by me. I understand that full payment is required at the time services are provided. If I have any issues with payment today, I will inform Pets First Veterinary Clinic before services are provided.I further, understand that I have the right to request a written estimate for any and all diagnostic tests, procedures and treatments that I elect to have performed by Pets First Veterinary Clinic. By signing below, I am authorizing veterinary care be provided for the above described pet, presented  by my directed agent(s) to Pets First Veterinary Clinic. I understand that veterinary care may include, but is not limited to, examination, prescription or administration of medication or medical treatment including surgery. I agree that in the event of nonpayment, I will bear the cost of collection, court costs and reasonable legal fees should such action be required. I agree that a photocopy of this authorization shall be valid as the original.

Signature of Owner or Authorized Agent __________________________________________________   Date ________________________