Welcome to Little Friends of Ferndale. Thank you for giving us the opportunity to care for your pet. Please help us to support your animal family’s needs by sharing some information with us. Acct.# Client Information Date Date Format: MM slash DD slash YYYY Owner’s Name:Primary Phone:Address Street Address City ZIP / Postal Code Co-Owner/SpouseCo-Owner/Spouse Phone:Employer:Work Phone:Email Address : Who referred you to LFOF?In case of an emergency involving your pet, and we are unable to contact you, who would you like us to contact?Name:PhonePrevious veterinary hospital that took care of your pet(s)?Please note that full payment is due at the time services are rendered. We will gladly prepare a written estimate for your visit – just ask a receptionist. We accept cash, Visa, Discover or Mastercard (debit or credit). We do not accept personal checks.Signature of Owner/Authorized AgentPatient InformationPet’s Name:Date of Birth/Age Date Format: MM slash DD slash YYYY Species (Dog/Cat)BreedColorGenderMaleFemaleSpayed/NeuteredYesNoSpayed/NeuteredYesNoMicrochippedYesNoOn Heartworm Preventative? What kind?YesNowhat kindOn Flea/Tick Preventative? What kind?YesNowhat kindWill dog go to kennel, groomer, dog park, or training class?YesNoDoes cat go outside?YesNoAny known allergies? Or adverse reactions to vaccines/medications?Any previous serious illness/surgeries?Authorization release of information for Media or Website Publication I authorize Little Friends of Ferndale Veterinary Care and its agents to take photos of my pet or pet’s condition and copyright, use and publish the same in print and/or electronically. I agree that Little Friends of Ferndale Veterinary Care may use such photographs or my pet with or without my name and for the lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.Untitled I have read and agree the above statement. SignatureDate Date Format: MM slash DD slash YYYY Printed name
