Owner’s Name*

Email*

D.O.B

S.S#

Driver’s License # (please give D.L to receptionist to photo copy) (Required)

Mailing Address (Required)

City*

State*

Zip*

Primary Phone*

Alternate Phone# ​​​​​​​

Employer

How did you hear about us? (Required)

Referral - Who may we thank

Patient Information

Pet’s Name*

Pet Type (Required)

Gender/Alteration status (Required)

Breed (Required)

Color (Required)

Date Of Birth or Aprox. (Required)

Past veterinarian(s) where records may be requested? (Required)

Does your pet have any drug sensitivities or reactions to vaccines?

If Yes, please provide list and records.

Any issues you would like to discuss with the veterinarian today? (Required)

We accept cash and check, Debit Card, all Major Credit Cards, care Credit

Exp.

Sec (CVV)

I hereby authorize Broad River Animal Hospital and it’s veterinarians to examine, prescribe for, and treat the above pet and any other pets on my account. I release Broad River Animal Hospital and it’s veterinarians from any liability related to any such care. I assume full responsibility for all charges incurred and I understand that a deposit may be required for hospitalization and/or treatment.

I understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED and agree t pay for services. I understand that there is a minimum $25.00 service charge for all returned checks. Any unpaid accounts more than 90 days past due will be sent to a collection agency and 1.5% interest fee on balance.