Owner Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Animal’s name *

Species (dog, cat) *

Breed *

Color and Markings *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Animals Medical History

Vaccinations; please give the date last received.

Dogs

Cats

FVRCP
Leukemia
Rabies

Lab Tests

Stool
Heartworm
Leukemia
FIV

Allergic to any medications or food?

Any previous injuries or surgery?

Any previous disease or parasites?

Brand of food fed

Previous medical forms can be requested from

In case we are unable to contact you, please call

Reason for today’s visit

Social Media Consent

Cactus Pet Hospital would like your permission to use images taken, case history of you and/or your pet on our social media and website pages.

YES, I authorize the use of my pet’s picture and/or story
NO, I DO NOT authorize the use of my pet’s picture and/or story

FINANCIAL RESPONSIBILITY: I understand that I will be expected to pay for services at the time of each visit. I further agree to pay all finance charges, collection costs, attorney fees, and other costs that may be incurred to enforce collection of any amounts outstanding.

In order to suit your individual needs - Which most applies to you

I want the best medical care available for my pet; please recommend anything that you feel is necessary for good health.
I want good medical care for my pet, but there is a limit to what I can have done.
I want you to only perform the services I request.

How did you learn about our hospital?

Hospital sign
Internet
Veterinary referral
Personal recommendation

Who may we thank?

Consent For Medical Services In the event of illness or if emergency care is needed, Cactus Pet Hospital will try to contact me first. If unable to reach me, I authorize them to treat my pet and assume full responsibility of payment for those services. In the event that my animal is not picked up within five days of the release date, the animal will become property of the hospital and will be dispositioned as required to settle the account. We extend our knowledge and capabilities in order to serve you and your pet. However, medicine isn’t an exact science and offers no guarantees. Therefore, we at Cactus Pet Hospital are unable to guarantee services. We do recognize and appreciate that you entrust the care of your special pet with us.

To prevent the spread of infectious diseases and parasites, all hospitalized animals must be current on all vaccines and free of internal and external parasites. *

I authorize the doctor to provide vaccines and parasite control as needed for my pet.

Signature *

Date *

Online Form

New Patient Registration Form