Client's Name (required)
Pet's Name (required)
Daytime phone number where you may be reached today (required)
By checking this box, I authorize the doctor to treat my pet as necessary should he/she be unable to contact me at the number(s) provided. (required)
In the space provided, please briefly describe the reason for your pet's visit: (required)
Please leave this field empty.
After your pet is examined, the doctor or technician will call and discuss any further diagnostics or treatment.
Parasites: If parasites (fleas, ear mites, intestinal parasites, etc.) are found on your pet while visiting our facility, we will treat the pet with necessary treatment at the owner's expense for the protection of your pet and that of others in the hospital.
Rabies Vaccinations: All pets over six months of age are required to be vaccinated for rabies according to state law if its health condition allows. If your pet has not had a rabies vaccine prior to his/her visit, or if proper documentation cannot be provided, the pet must be vaccinated for rabies while here, at the owner's expense.
By checking this box, I am giving consent to the veterinarians of Cheat Lake Animal Hospital to examine and treat any emergency conditions. I also acknowledge that I understand the information on this form AND the special notes explained above. (required)
Please type your name here in place of a signature (required):