Owner's Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pet's Birthday

MM

DD

YYYY

Pet's Sex

Male

Female

Pet is Spayed or Neutered

Yes

No

Do you have additional pets?

Yes

No

#2 Pet's Birthday

MM

DD

YYYY

#2 Pet's Sex

Male

Female

#2 Pet is Spayed or Neutered

Yes

No

#3 Pet's Birthday

MM

DD

YYYY

#3 Pet's Sex

Male

Female

#3 Pet is Spayed or Neutered

Option 1

Option 2

Emergency Contact *

First Name

Last Name

Emergency Contact *

(###)

###

####

To prevent the spread of infectious disease and parasites, all hospitalized and boarding animals must be current on all vaccines and free of internal and external parasites. *

I Agree

I authorize the Doctor to provide the necessary vaccines, any parasite control, and any care deemed appropriate and necessary for my pet. *

I Agree

I agree to pay at the time services are rendered, unless prior arrangements have been made with the Doctor. I understand that interest and service charges will be applied to any past due balance on my account. *

I Agree

With my selection, I grant Little Woods Animal Hospital permission to use any photographs taken of myself or my pet, in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become Little Woods Animal Hospital property and will not be returned. I hereby authorize Little Woods Animal Hospital to edit, alter, copy, exhibit, publish, or distribute this photo for purposes of publicizing programs or for any other lawful purposes. *

In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization.

I Consent

I Do Not Consent