Your Information

First Name *

Last Name *

Your Drivers License Number *

Email *

*We use e-mail for pet portal access, newsletters, reminders, client education, and other notifications. We NEVER sell email addresses.

Main Phone *

Your Employer

Work Phone

Street Address *

City *

State *

Postal code *

Your Partner/Spouse's Information

Spouse/Partner

Spouse/Partner Phone

Spouse/Partner Employer

Spouse/Partner Work Phone

Spouse/Partner/Other Email

In Case Of An Emergency

In case of EMERGENCY, please call: *

Main Phone

Work Phone

Spouse/Partner Phone

Spouse/Partner Work Phone

Communication Preferences

Do you prefer email/electronic communications over paper? *

Yes

Both

Would you like to receive text message reminders of appointments? *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Billings Animal Family Hospital. Message frequency varies. Message & data rates may apply.

How did you first learn of our hospital? *

At your request we will gladly discuss cost of services and prepare a written treatment plan for procedures. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, local checks. debit cards, VISA, MasterCard, Discover and American Express. We also offer CARE CREDIT Payment Plans. Please ask if you would like to apply.

I agree to be responsible for authorizing procedures and/or paying for services

Signature *

Clear

Date Signed *

Animal Identification and Medical Information

Pet #1

Name *

Animal Type *

Breed *

Age *

Sex *

Description/Color *

Date Of Birth *

Length of Time Owned *

How did you obtain them? *

Previous Hospital/Veterinarian *

Microchip Number *

Pet #1

Vaccinations *

DHPP *

Bordetella *

Rabies *

FVRCP *

FELV *

Any Other Vaccines?

Pet #1

Groomer *

Kennel *

Current Medication *

Special Diet *

Prior Illness/Accidents *

Prior Surgery/Dentistry *

Would you like to add another pet? *

Pet #2

Name *

Animal Type *

Breed *

Age *

Sex *

Description/Color *

Date Of Birth *

Length of Time Owned *

Pet #2

Vaccinations *

DHPP *

Bordetella *

FVRCP *

FELV *

Any Other Vaccines?

Pet #2

Groomer *

Kennel *

Current Medication *

Prior Illness/Accidents *

Special Diet *

Prior Surgery/Dentistry *

Would you like to add another pet? *

Pet #3

Name *

Animal Type *

Breed *

Age *

Description/Color *

Sex *

Date Of Birth *

Length of Time Owned *

Pet #3

How did you obtain them? *

Previous Hospital/Veterinarian *

Vaccinations *

DHPP *

Bordetella *

Rabies *

FVRCP *

FELV *

Any Other Vaccines?

Pet #3

Groomer *

Kennel *

Current Medication *

Prior Illness/Accidents *

Special Diet *

Would you like to add another pet? *

Pet #4

Name *

Animal Type *

Age *

Sex *

Description/Color *

Date Of Birth *

Length of Time Owned *

Pet #4

How did you obtain them? *

Previous Hospital/Veterinarian *

Microchip Number *

Vaccinations *

DHPP *

Bordetella *

Rabies *

FVRCP *

FELV *

Any Other Vaccines?

Pet #4

Groomer *

Kennel *

Current Medication *

Prior Illness/Accidents *

Special Diet *

Prior Surgery/Dentistry *

Would you like to add another pet? *

Pet #5

Name *

Animal Type *

Breed *

Age *

Sex *

Description/Color *

Date Of Birth *

Length of Time Owned *

Pet #5

Pet #5 How did you obtain them? *

Previous Hospital/Veterinarian *

Vaccinations *

Microchip Number *

DHPP *

Bordetella *

Rabies *

FVRCP *

FELV *

Any Other Vaccines? *

Pet #5

Groomer *

Kennel *

Current Medication *

Prior Illness/Accidents *

Special Diet *

Prior Surgery/Dentistry *

Appointment Date

Please provide the date of your scheduled appointment *

What is the reason for your visit today? *

Any other questions/concerns/comments?

Billings Animal Family Hospital

New Patient/Client Information