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*
1st Pet Information
Pet's Name
*
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*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
or if other species
Breed (if known)
Date of Birth or Age (if known)
Description
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Would you like to add another pet?
*
Yes
No
Second Pet Information
Pet's Name
*
Species
*
Dog
Cat
Rabbit
Ferret
Bird
Reptile
or if other species
Breed (if known)
Date of Birth or Age (if known)
Description
Sex
Neutered Male
Spayed Female
Male
Female
Unknown
Veterinary History
Previous Veterinarian
Facility Name
Whom do we thank for the referral?
Fountain City Animal Hospital Policies
Records Release
*
I give permission for Fountain City Animal Hospital to obtain and/or release my records to other veterinary, grooming, or boarding facilities.
I give permission.
For the protection of our patients, all pets staying in the hospital (grooms, surgeries, boarders, and hospitalization) must be current on the following:
Dogs:
Distemper vaccination, Rabies vaccination, Parvo vaccination, Canine Influenza vaccination, Bordatella vaccination, and a stool exam within the last 2 months
Cats:
Distemper vaccination, Rabies vaccination, and a stool exam within the last 2 months
If at any time you would like a printed estimate, please ask any of our staff. A deposit may be required for services. We accept all major credit cards, checks, and cash.
There will be a $40 fee for any returned check.
I authorize Fountain City Animal Hospital to post my pet's picture on Facebook/Internet
*
Yes
No
Please choose your preferred method of contact for vaccine and appointment reminders and any updates from our hospital.
*
*By participating, you consent to receive text messages sent by an automatic telephone dialing system. Consent to these terms is not a condition of purchase.
Email
Phone
Mail
Text*
Consent/ Signature
*
By checking this box, I confirm that all the above information is correct to the best of my knowledge. That I understand the policies and requirements of Fountain Animal Hospital
I agree to the policies above in full
Today's Date
*
Date Format: MM slash DD slash YYYY
Additional Comments
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Who We Are
Our Team
Take A Tour
Promotions
Careers
What We Do
Wellness Exams
Vaccination
Diagnosis & Treatment
Surgery
Dentistry
X-Ray & Ultrasound
Laboratory
Pharmacy
Flea & Tick Control
Microchipping
Behavioral Counseling
Grooming
Boarding
Prescription Pet Foods
Your Pet
Cat Health
Dog Health
Patient Forms
Resources
Pet Health Library
Pet Health Checker
How-To Videos
Pet Food Recalls
Product Recalls
News
Pet Insurance
Purina Vet Direct
New Clients
Client and Patient Information Form
Payment Options
Pharmacy
Contact
Request Appointment
Prescription Refill and Food Order Request Form
Emergencies
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