Complete Your Booking - Wasilla Veterinarian

Owner Details:

Owner's Name *(Required)

(Person must be at least 18 years of age)

Email *(Required)

Home Phone *(Required)

Cell Phone *(Required)

Work Phone

Mailing Address *(Required)

Street Address City State ZIP Code

Pet Details:

Pet's Name *(Required)

Date of Birth *(Required)

Species *(Required)

Dog
Cat

Breed *(Required)

Color

Gender *(Required)

Male
Female

Spayed/Neutered *(Required)

Yes
No

Previous Veterinarian (if any)

Emergency Contact:

Emergency Contact Name *(Required)

(Person must be at least 18 years of age)

Home Phone *(Required)

Date of Last Vaccinations:

Dog:

Distemper/Parvo

Bordetella

Rabies

Cat:

Distemper/Parvo

Leukemia

Rabies

Other – (specify)

Does your pet have any Allergies?

Yes
No
Unknown

List

Is your pet currently receiving any medication or a special diet?

Yes
No
Unknown

List any medications.

Reason for coming to the clinic today.

How did you hear about us?(Required)

Please specify(Required)

Promotion Code(Required)

Authorization:

PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED

How is account to be paid?

Cash
Check
Visa/MasterCard/Discover/Amer-Exp
CareCredit

Consent *(Required)

Authorization

I am the owner or authorized agent of the above mentioned animal and am responsible for it and have authorization to execute consent. I hereby authorize treatment of this animal and performance of such surgical or therapeutic procedures as the doctor determines to be indicated and use of such anesthetics as deemed advisable. I also authorize the use of microchip scanning for identification purposes. It is understood that all unpaid accounts are subject to a monthly billing service charge of $18.00 as well as any incurred cost of collections, and attorney’s fees. The animal will be considered abandoned within seven days of written notice to the above address. After such time All Creatures Veterinary Clinic, Inc. may destroy, sell, or otherwise dispose of the animal.

Signature

Phone

This field is for validation purposes and should be left unchanged.

COMPLETE YOUR BOOKING – Almost Done, Deposit + Form Required

Client Intake Form