I declare that the statement(s) above (regarding COVID-19) is/are, to the best of my knowledge, accurate with regard to myself and anyone who will be accompanying me for today's visit. *

Yes
No

When in the exam room with you, do you prefer that our doctors and staff be wearing masks? *

Yes
No

If you consent to having us obtain your pet's medical records (e.g. vaccine history, heartworm testing, etc.) from another veterinarian, please enter the name and phone number of the previous veterinary clinic or hospital. *

If you refuse, or there is no other vet, enter "Refuse" or "NA".

Occasionally we feature pets on our website and social media (Facebook, Instagram, etc). May we use photo/video of your pet(s) in this capacity? *

Yes
No

Owner Information

Name of authorized owner *

First

Last

Spouse

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Driver's license # *

(This is required by the DEA)

State issued *

e.g. Michigan, Ohio, etc.

Your date of birth *

(This is required by the DEA)

Pet Information

Patient/pet name *

Species *

Dog
Cat
Other

Breed *

Date of birth

(If you don't know, give your best guess)

Age *

(If you don't know, give your best guess)

Color *

e.g. brown, black and white, etc.

Sex *

Male
Female

Spayed/Neutered? *

Yes
No
Unsure

Reason for visit *

e.g. Wellness exam, vaccine, injury, etc.

Additional patients/pets

If you have more than one pet, please enter their information here in a similar format (e.g. "Rex, dog, Chocolate Lab, born 4/15, age 5, brown color, neutered male")

Additional caretaker

If desired, you may provide the name and phone number of one other person (trusted friend, family member, etc.) you authorize to order treatment or obtain patient information.

Authorization for treatment *

Please authorize treatment by entering your name and today's date in the box above. You are authorizing the release of your pet's medical records and will assume responsibility for all fees incurred. Note: All professional fees are due at the time services are rendered. Monies owed for services not paid at the time services are rendered are subject to billing fees and interest.

Veterinary Records

If you have records for your pet(s), you can upload them below. Additional records can also be emailed to "clientinfo@annarboranimalhospital.com". When finished with the form, tap or click "Submit" below. Thank you!

File Upload 1

Click or drag a file to this area to upload.

File Upload 2

Click or drag a file to this area to upload.

File Upload 3

Click or drag a file to this area to upload.

File Upload 4

Click or drag a file to this area to upload.

New Client and Patient Form

Owner Information

Pet Information

Veterinary Records