Name *

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number

Cell Number

Work Number

Email *

How do you most prefer to be contacted? *

Home Number
Cell Number
Work Number

Spouse

Best Phone Number to Reach Spouse

Do you have a pet sitter, neighbor, relative, and/or friend who are authorized to bring in pet(s) and make treatment decisions? *

Yes
No

How were you referred to Bay Animal Hospital?

Who referred you for the Re-fur a friend program?

Please Specify Other *

Pet Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

I hereby authorize Bay Animal Hospital to render surgical and medical care for my pet(s) as deemed necessary by the veterinarian.
I understand that payment is required in full at time of discharge.
I understand I may be asked to leave a 50% down payment before surgical procedures and that no guarantee can be given to the outcome.
I understand that Bay Animal Hospital does not accept checks or offer payment plans. If you require a payment plan please ask the Receptionist for a Care Credit application and brochure. Care Credit is a 6 month no interest medical credit card.
Veterinary service during nighttime hours, some daytime hours, and/or weekends, is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours.
I understand personal items (blankets, toys etc.) may not be returned if left at Bay Animal Hospital.
I understand that fecal testing is recommended every 6 months for my pet and according to the Centers for Disease Control and Prevention, dog and cat parasites can be transmitted to humans and can cause potentially serious health problems.
I understand that eliminating intestinal parasites from my pet is essential and is extremely important for the health of my family.

I have read and understand the above statements and authorize Bay Animal Hospital to render surgical and medical care for my pet(s) as deemed necessary by the veterinarian. *

I have read and understand the above statements and authorize Bay Animal Hospital to render surgical and medical care for my pet(s) as deemed necessary by the veterinarian.

Signature *

Clear Signature

Date *

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