Dothan Animal Hospital

1846 S. Oates Street
Dothan, AL 36301

(334)793-9779

www.dothananimalhospital.com

Dothan Animal Hospital - New Client Check In

 

Thank you for giving us this opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information we will need as we provide your pet’s needs.

New Client

Name (required)
First Name (required)
Last Name (required)
Spouse/Co-Owner's Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home Phone Number (required)

Cell-Phone Number (required)

Other Contact Numbers

E-Mail Address (required) :
Birth Date (required)

Employer

Work Phone

Spouse/Co-Owner Employer

Spouse/Co-Owner Work Phone

We will gladly prepare a written estimate if you desire (please ask any staff member). This will be important to you since all 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 take Visa, Mastercard, Discover, American Express, Care Credit, and Reliant. There will be a $35.00 service charge on all returned checks.
To prevent the spread of infectious diseases, hospitalized and boarded patients must be current on all vaccines as required by hospital policy. Those patients must also be free from external and internal parasites.
The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice. The person signing below will be responsible for all charges incurred in the care of this pet(s).
Signature of Responsible Agent for pet(s) (required)

(required)
(I agree that my electronic signature is the legal equivalent of my manual signature)
Date (required)

How/Why did you select us?

ESSENTIAL PET INFORMATION
Type of Pet (required)
Canine
Feline
Pet's Name (required)

D.O.B.

Sex: (required)
Male
Female
Neutered/Spayed
Neutered
Spayed
Color

Date of last vaccinations
Please list any additional pets here (include species, pet name, gender, D.O.B, color, if spayed/neutered, and date of last vaccinations)


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