Owner Information

Owner First Name *

Owner Last Name *

Secondary Owner / Authorized Agent Name

Email *

Primary Phone *

Mobile Phone

Work Phone

Address *

City *

State *

Zip Code *

Employer *

Occupation *

Date of Birth *

How did you hear about us? *

Primary Care Veterinarian

Internet

Friend / Family

Community Event

Signage

Printed Publication

Radio

Other

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

What date and where were their last vaccinations administered? *

Gender *

Spayed or Neutered? *

What activities do you do with this patient? *

Family Pet

Service Animal

Hunting

Agility

Other

About how much of your pet's time is spent outside? *

Less than 10%

10 - 50%

50 - 100%

Does your pet have any previsouly diagnosed conditions that we should know about? (Injuries, heartworms, kidney disease, diabetes, etc) *

Is your pet on any routine medications? *

May we obtain your pet's records from your previous veterinarian? *

Yes

What heartworm preventive is your pet on? *

Social Media Release

WE WOULD LIKE TO BE ABLE TO SHARE YOUR PET’S PICTURE ON FACEBOOK AND OTHER FORMS OF SOCIAL MEDIA FOR THE ENJOYMENT OF ALL OF OUR CLIENTS. DO YOU GIVE KAH PERMISSION TO SHARE THIS TYPE OF INFORMATION IN THIS MANNER? *

Yes

Our staff is trained to hold your pet during examination and treatment. Please understand we
cannot be held responsible for any injury incurred to you or your pet if you attempt to assist in the
restraint of your pet.

I hereby authorize any veterinarian employed by Kay Animal Hospital to perform diagnostic, therapeutic, and surgical procedures as that are necessary and advisable for treatment and maintenance of my pet’s health and well-being. The nature of such services will be previously agreed upon and describe to me. While I expect all procedures to be done to the best of the abilities of the professional staff, I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I understand that I assume financial responsibility for all services rendered. I have read and understand the above statements and agree to all terms therein.

All payments are due at the time of services rendered.

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