Client Information
Owner's Name
*
First Name
Last Name
Co-Owner's Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone
*
Enter phone number
Format: (000) 000-0000.
Cell Phone
*
Enter phone number
Format: (000) 000-0000.
I allow Edgewater Animal Hospital to contact me through text messages.
I agree
Preferred method of contact
Email
Home Phone
Cell Phone
How did you hear of us?
Search engine
Referral/through a friend
Business card
Website
Other
Pet Information
Please bring any previous vet records you have to give to the receptionist.
Pet's Name
*
Species
*
Dog
Cat
Color
*
Age
*
Breed
*
Sex
Male
Female
Spayed / Neutered
Yes
No
Previous Medical History
Add Another Pet
Yes
No
SECTION: PET #2
Pet #2 Information
Pet #2's Name
Species
Dog
Cat
Color
*
Age
*
Breed
*
Sex
Male
Female
Spayed / Neutered
Yes
No
Previous Medical History
Add another Pet
Yes
No
SECTION: PET #3
Pet #3 Information
Pet #3's Name
Species
Dog
Cat
Color
*
Age
*
Breed
*
Sex
Male
Female
Spayed / Neutered
Yes
No
Previous Medical History
Add another pet
Yes
No
SECTION: #4
Pet #4 Information
Pet #4's Name
Species
Dog
Cat
Color
*
Age
*
Breed
*
Sex
Male
Female
Spayed / Neutered
Yes
No
Previous Medical History
SECTION: END / SUBMIT
I agree to receive communications by text message regarding my pet's care from Edgewater Animal Hospital. You may opt out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy (
https://www.edgewatervet.com/privacy
) to learn how your data is used.
I agree
I understand that FULL PAYMENT IS DUE AT THE TIME SERVICE IS RENDERED and that a DEPOSIT IS REQUIRED FOR ANY HOSPITALIZED PET. All unpaid balances are subject to a 1.5% per month interest charge. Returned checks are subject to the incurred returned check fee. In the event legal action is required to recover an unpaid balance I agree to pay all interest, court costs and attorney’s fees. I authorize the release of my pets’ medical records to Edgewater Animal Hospital and hereinafter waive any written release requirement.
Use your mouse or finger to draw your signature above
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