CLIENT INFORMATION

Primary Client *

First

Middle

Last

Email Address: *

Cell Phone *

Home Phone

Work Phone

Please indicate your primary contact:

CELL
HOME
WORK
EMAIL

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Secondary Client (Spouse/Co-Owner)

First

Last

Cell Phone

Home Phone

Work Phone

Emergency Contact Name *

Phone *

How did you hear of our practice? *

PATIENT INFORMATION

Pet Name *

Species *

Age/D.O.B *

Breed *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a second pet? *

Yes
No

Pet Name *

Species *

Age/D.O.B *

Breed *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a third pet? *

Yes
No

Pet Name *

Species *

Age/D.O.B *

Breed *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a fourth pet? *

Yes
No

Pet Name *

Species *

Age/D.O.B *

Breed *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Name of Previous Veterinary Office *

May we contact them to get your pets’ previous history? *

DUE TO STATE LAW REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION.

Do you have verification of your pet's previous Rabies vaccination? *

Yes
No

Prior Surgery *

Prior Illness *

By signing below, you acknowledge that you are the owner of the pet(s) listed within this form and you are responsible for all fees assessed during your pet(s) visit will be paid for at the time of service. *

I have read and accept the policy.

Signature *

Clear Signature

Date *

Policy and Conduct Page

Please review the following policies, initial where indicated, then sign and date the bottom of this form.

Payments– Full payment is due at the time of service. We accept Cash, Check, Visa, Mastercard, Discover, Scratch Pay and Care Credit. *

I have read and accept the policy.

New Client Deposit – New clients are required to make a deposit (equal to one exam fee per animal) to secure their appointment. This will be applied to your account; please note that this deposit is forfeited if you cancel with less than 4 hours’ notice or fail to show up for your appointment. *

I have read and accept the policy.

No Show/Late Policy – Appointments are considered as a “No Show” and will be charged for the appointment if they are more than 15 minutes late, or if the appointment is cancelled less than 4 hours prior to the appointment start time. Clients that are more than 15 minutes late may need to be rescheduled. *

I have read and accept the policy.

Late Patient Pick-up Charge – Aurora Animal Hospital closes at 6pm on Wednesdays and Fridays. If you arrive after 6pm to pick up your patient (unless otherwise scheduled specifically with your veterinarian), you will be charged $15.25 for every 15-minute increment after 6pm. *

I have read and accept the policy.

Prescription Refill Requirements – We require a minimum of 24 hours’ notice to process any refill requests, whether the medication is filled in house, or is written to an outside pharmacy. *

I have read and accept the policy.

Rabies Requirement – all patients are required to be up to date on Rabies vaccinations, and owners are responsible for providing proof of Rabies if the vaccine was not given here at Aurora Animal Hospital. Rabies vaccines are required by law but also keep your pet and our staff safe in the event of an animal bite. *

I have read and accept the policy.

Exam Requirements – a. New patients are required to have an exam with one of our veterinarians prior to scheduling Technician Appointments, Surgeries/Sedated Procedures, or Dental Procedures. b. Patients are required to have an Exam with a Veterinarian at least once per year to continue receiving any prescription medications. c. Patients are required to have an Exam with a Veterinarian at least every 3 years to continue receiving vaccinations, anal gland expressions, nail trims, etc, *

I have read and accept the policy.

Patient Transfers – In order to transfer patients to or from any account, permission must be granted by the primary client on the account prior to the chart being transferred. *

I have read and accept the policy.

Client Conduct – We expect all clients and their guests to treat our staff, veterinarians and fellow clients with courtesy and respect. The following behaviors will not be tolerated and may result in a request to leave the premises or even termination of the client-hospital relationship. • Verbal abuse, including shouting, name-calling, or offensive language. • Threatening or intimidating actions or language. • Disruptive behavior that may interfere with other pets’ care. • Discrimination or harassment of any kind. *

I have read and accept the policy.

We are committed to maintaining a respectful and professional environment for our staff, clients, and patients. Please help us achieve this goal by understanding and adhering to these above-named policies.

By signing below, you agree you have received, reviewed and understood these policies as they are written. *

I have read and accept the policy.

Signature *

Clear Signature

Date *

New Client Form

New Client Form

CLIENT INFORMATION

PATIENT INFORMATION

DUE TO STATE LAW REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION.

Policy and Conduct Page

Ready to Visit?

Have a Question?

Location

Contact Information

Hours

If you have an emergency outside of our business hours, please call the After-Hours Veterinary Emergency Clinic (907) 479-2700, or contact Vet Triage. Alternatively, you can visit Fairbanks Emergency Vet for additional resources.