Thank you for visiting our hospital. We look forward to getting to know you and your pet. Please help us to provide the best care possible for your pet by taking a moment to fill out this form. Practice None Patient's Name * Client / Owner Information Name Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Home Phone Cell Phone Work Phone Email * Date of Birth Spouse / Co-Owner Information Name Occupation Cell Phone Work Phone Email How did you hear about us? How did you hear about us? - None -ReferredPhone BookInternet (Bing/Google/Yahoo/Yelp)Social Media (Facebook/Twitter)Drive By2nd OpinionConvenience Other Doctor ReferralIf you have been referred to us by another veterinarian, please provide their information below. Doctor's Name Hospital Name State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Phone Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Sex - None -MaleFemale Spayed / Neutered? - None -YesNo Please tell us about your pet(s) Name Type of Pet - None -DogCatOther (Please fill in below) Other Breed Color Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Sex - None -MaleFemale Spayed / Neutered? - None -YesNo By signing below, I confirm that this information is correct, and that I am the client responsible for the pet(s) listed on my account I understand that FULL PAYMENT IS DUE AT THE TIME OF SERVICE IS RENDERED and that a DEPOSIT IS REQUIRED FOR ANY HOSPITALIZED PET. We will gladly prepare a written estimate of service fees if you desire, please ask our doctor or receptionist. All unpaid balances are subject to a 1.5% per month interest charge. There will be a service charge for any check returned unpaid. In the event of default of any payment required by this agreement when due, the entire unpaid balance of principal and interest shall become due and payable immediately, without notice, at the election of Meridian Veterinary Clinic & Hospital. If Meridian Veterinary Clinic & Hospital turns the account over to collection, MVC&H shall have the right to recover the cost of collection including but not limited to collection agency fees and reasonable attorney’s fees. I authorize the release of my pets’ medical records to Meridian Veterinary Clinic & Hospital and hereinafter waive the written release requirement. To prevent the spread of infectious diseases, all hospitalized patients must be current on vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice. Please sign your name below using your mouse as a cursor: Signer Name *