Client Information Sheet – Rice Village Animal Hospital

Title *

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Employer

Work Phone

Cell Phone

E-mail *

Who would you like to add as a secondary contact? *

If Other, please explain:

Title

Name *

First

Last

Employer

Work Phone

Cell Phone

E-mail

How did you learn about our hospital?

Please let us know which website

Please let us know who told you about so we can thank them!

If Other, please explain:

Pet's Information

(Please list each pet that you own)

Pet's Name *

Sex

Male
Neutered Male
Female
Spayed Female

Age/DOB

Species

Breed

Color

Would you like to add information for another pet? *

Yes
No

Pet's Name

Sex

Male
Neutered Male
Female
Spayed Female

Age/DOB

Species

Breed

Color

Would you like to add information for another pet? *

Yes
No

Pet's Name

Sex

Male
Neutered Male
Female
Spayed Female

Age/DOB

Species

Breed

Color

Would you like to add information for another pet? *

Yes
No

Pet's Name

Sex

Male
Neutered Male
Female
Spayed Female

Age/DOB

Species

Breed

Color

Hospital Policies

Our hospital will not release your pet to any person not specifically authorized by you. Please list all persons you wish to pre-authorize for receiving your pet:

Do you authorize us to obtain information about your pet(s) from another veterinarian, kennel, breeder or any other person? *

Yes
No

Do you authorize us to release information about your pet(s) to another veterinarian, kennel, breeder or any other person? *

Yes
No

Do you give permission for Rice Village Animal Hospital to take and display photographs of your pet(s) on their website, Facebook page or in their Hospital? *

Yes
No

(If you decide you no longer want your pet’s picture displayed, it will be removed within 14 business days upon submission of a written request to do so.)

Our hospital requires that every pet left in our care to be current on vaccines as determined by our veterinary staff and be free of internal and external parasites. Treatment or vaccines will be administered at the expense of the owner, including doctor’s exam fees. *

I have read and understand

All pets left in our care overnight must have had an examination by our doctors within the last twelve months. *

I have read and understand

Pets picked up within one hour after closing time Monday- Saturday will be assessed one-half of the regular boarding fee. Regular boarding fees and after hours release fees will be applied if picked up during any other time. *

I have read and understand

By City of Houston ordinance, Rice Village Animal Hospital must report any rabies vaccination administered to any pet with the following information for city licensing: • A description of the dog or cat including its breed, age, color and sex; • Whether the animal has been neutered (if known or determinable by the veterinarian); • The serial number of the vaccination tag furnished; • The name and the current address of the person owning or keeping the animal; and • The number of the City of Houston registration tag worn by the animal, if any. *

I have read and understand

If you would like a copy of this ordinance please request one from the receptionist.

Our doctors will proceed to treat medical conditions, which occur or exist in pets while left in our care. Any such treatment will be at the expense of the owner. If you do not want your pet treated without a phone call, you must leave a number where you may be reached during regular office hours, and inform the receptionist at the time of drop off to have the doctor call you before treatment is initiated. In the event of an emergency, the doctor will proceed to treat your pet without first speaking to you. *

I have read and understand

If you desire an estimate prior to any treatment please ask the receptionist for a written estimate. *

I have read and understand

Payment for services is due at the time the pet is released. We accept Master Card, Visa, Discover, American Express, Care Credit, cash and checks. Hospital cases may require a 50% deposit of the estimated cost at the onset of treatment. *

I have read and understand

Date *

Your signature here verifies that you have read and understand all the above information. *