THE PET HOSPITAL

5100 N. Star Road

Meridian, Idaho 83642

Your Name ___________________________________

Spouse's Name ____________________________________

Street Address or P.O. Box Number ______________________________________________

City _____________________ State ______________________ Zip Code _______________

Home Phone __________________________ Work Phone ___________________________

Email Address(es) ____________________________________________________________

Reason for your visit today _____________________________________________________

Your place of employment ______________________________________________________

Your Spouse's place of employment ______________________________________________

How did you choose this hospital ________________________________________________

If referred, who may we thank __________________________________________________

What was your reason for leaving your last veterinarian _____________________________

What is your pet's name _______________________________________________________

If you have other pets, please complete the information below:

Name	Breed	Sex	Age
________________________________________	_____________________________________	__________	______
________________________________________	_____________________________________	__________	______
________________________________________	_____________________________________	__________	______
________________________________________	_____________________________________	__________	______

Consent for Veterinary Services

I authorize the administration of preventative health care treatments, general and surgical prodedures as are considered therapeutically and diagnostically necessary on the basis of findings during the course of evaluation and/or treatment. I also authorize the use of anesthetic agents as are deemed necessary. I assume financial responsibility of all charges incurred to this patient. I am also aware of the fact that payment is due in full at the time of veterinary services.