Client Information Intake Form

Balsam Animal Hospital Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become acquainted, please complete the following.

COMPLETE ALL REQUIRED FIELDS WITH THE ASTERISK. IF YOU GET AN ERROR YOU NEED TO FIND THE MISSING REQUIRED FIELD.

If you do NOT have a scheduled appointment please complete request the Date and Time below for your suggested appointment day.

If you already have an appointment you can skip the Date and Time fields.

Please complete the rest of the Intake form for a scheduled appointment or new appointment.
Reason for visit*
Have you been here before?*
- Yes
- No
Select Veteranarian*
- Paul Kern
- First Available
Requested Date (1)
MM slash DD slash YYYY
Requested Time (1)

: Hours

Minutes

AM/PM
Requested Date (2)
MM slash DD slash YYYY
Requested Time (2)

: Hours

Minutes

AM/PM
Requested Date (3)
MM slash DD slash YYYY
Requested Time (3)

: Hours

Minutes

AM/PM
Owner's Name*
First Last
Co-Owner's Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Place of Employment
Home Phone - Put Cell Phone Here if no Home Phone (required)*
Cell Phone
Alternative Phone
Email
Patient Information
Pet Number 1*
Species: Canine or Feline*
Date of Birth*
Color/Markings*
Gender: Spayed or Neutered*
Pet Name 2
Species: Canine or Feline
Date of Birth
Color/Markings
Gender: Spayed or Neutured
Pet Number 3
Species: Canine Or Feline
Date of Birth
Color/Markings
Gender: Spayed or Neutured
Preferred Method of Contact*
- Phone
- Email
Name of Other Hospitals your pet(s) have received medical treatment or vaccinations from:
Phone Number of Other Hospitals your pet(s) have received medical treatment or vaccinations from:
FULL PAYMENT IS REQUIRED AT TIME OF SERVICE. Deposits are required on major medical/surgical cases & emergencies that require hospitalization. We DO NOT carry open accounts, however, we accept all major credit cards & Care Credit. To prevent the spread of infectious diseases and parasites, surgical patients and hospitalized animals must be current on all vaccines and the pet must be free of internal and external parasites. I hereby authorize Balsam Animal Hospital to provide any vaccines and parasite control as needed. I understand and agree that I am financially responsible for any and all charges incurred while my pet is under the care of Balsam Animal Hospital.
Name
This field is for validation purposes and should be left unchanged.

Balsam Animal Hospital Client Form

Patient Information

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