Name*

First Last

Address*

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

Primary Phone*

Secondary Phone*

Primary Phone Type*

Home
Work
Cell

Secondary Phone Type*

Home
Work
Cell

May we contact you via text message (SMS)?*

Yes
No

May we contact you at work?*

Yes
No

Email:*

What is your preferred way of being contacted?

Phone
Text Message
Email

Is there someone else who is authorized to make decisions for your pet?*

Yes
No

Name*

First Last

Their Home Phone:*

Their Cell/Work Phone:

Pet Information

Pet’s Name

Breed

Date Born

Species*

Dog
Cat
Other

Sex*

Male
Female

Has your pet been spayed / neutered?*

Yes
No

Colors & Identifying Markings*

Does your pet have a microchip identification?*

Yes
No

In the last 12 months, has your Pet had:

A complete physical examination?*

Yes
No

Regular vaccinations?*

Yes
No

Do you have health insurance for your Pet?*

Yes
No

Willowbrook Veterinary Hospital advocates the use of pet health insurance. We can assist you with preparing, filing, and sending claim forms in order to expedite your reimbursement.

FINANCIAL POLICY: Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent and estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your pet. We accept cash, Visa, Mastercard, American Express, Discover, and CareCredit payments. We do not accept checks unless prior arrangements are made with the hospital manager and/or owner. There is a $50 fee for checks that are drawn against an account with insufficient funds. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. If you check the following space, this will indicate that you have read and accepted our financial policy:

I agree on all terms stated on this form.

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Pet Information