Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Would you like to add another pet?*

Yes
No

Second Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Payment Information*

Payment is due in full at the time that services are performed. We accept Cash, Visa, MasterCard, Discover, American Express, Scratch Pay, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made.

I Understand

Hours of Operations Disclosure*

Walk-In Hours:
Monday - Friday
8:00 am – 11:00 am
2:00 pm – 5:00 pm

Lobby Hours:
Monday - Friday
8:00 am – 1:00 pm
2:00pm – 6:00pm

Kennel Hours:
Monday – Friday
8:00 am – 12:00 pm
2:00 pm – 6:00 pm

After these hours, there will be no employees present to care for or monitor the health of any pets in the hospital. If your pet requires 24-hour care, you will be required to transfer your pet to the appropriate Veterinary facility that provides this level of care. *While we do have kennel staff on the premises Sunday – Saturday, pick up and drop offs will only be available Monday – Friday.

By checking below, you state that you understand the hours or operation for Pasquotank Animal Hospital and the level of care provided for said hours. You also agree that if you have decided to leave your pet at Pasquotank Animal Hospital overnight, he/she will be unattended after close of business and any problems that occur with your pet, you will not hold Pasquotank Animal Hospital or its staff members responsible.

I understand the above

Client Information Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

Second Pet Information

Contact

Hours

Emergencies