Skycrest New Patient Registration

Date 

Name     Spouse's Name 

Address     City State     Zip

Home Phone    Work Phone   Spouse's Work Phone

Place of Employment     Best Time To Reach You?

Social Security No    Driver's License No

E-Mail

How did you become aware of our hospital?

    Friend or Co-Worker -    Whom may we thank?

    Internet Search Engine   Yellow Pages    Hospital Sign    Other

TELL US ABOUT YOUR PET (Please Submit A New Form For EACH Pet)

Pet's Name         Dog    Cat    Other

Breed    Age or D.O.B.     Color   

Male    Female    Spayed    Neutered

YOUR DOG'S VACCINATION HISTORY

Rabies    DHLP Parvo Corona    Bordetella    Fecal Stool Sample   Heartworm Test/Prevention

YOUR CAT'S VACCINATION HISTORY

Rabies    DIST-Rhino Chlamydia    Leukemia Vaccine    Leukemia Test/FIV Test   Fecal Stool Sample

Has your pet had any previous serious illnesses or surgeries?  If so, please explain below.

Is your pet allergic to any medication or vaccination?    No    Yes    If so, what?

Is your pet currently on any special food or medication?    No    Yes    If so, what?

We will gladly prepare a written estimate if you desire (please ask our doctors or receptionist).  This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.  In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we accept all major credit cards, or we can establish a payment arrangement if approved in advance of the treatment. 

There will be a $25.00 service charge for any check returned unpaid.

   

To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites.  By clicking on the SUBMIT button below, you authorize this level of preventive care and you agree to pay the appropriate charges assessed in the discharge invoice.

By submitting this online form, I agree to be responsible for authorizing procedures and/or paying for services.