ANIMAL EMERGENCY AND REFERRAL CENTER
3984 South U.S. Highway 1 · Fort Pierce, FL 34982 Phone (772) 466-3441 · Fax (772) 466-0206
www.animalemergency.net

CLIENT/PATIENT INFORMATION SHEET

Date*

Owner's Name*

Owner's Address*

City, State, Zip*

Spouse's Name

Co-Owner's Name

Have you been here before with this or any other pet(s)?*
YesNo

If Yes, when?

If different pet(s), other pet’s name please?

Primary Phone Number* Phone Type* HomeWorkCellFax

Other Phone Number Phone Type HomeWorkCellFax

If a cell phone number is provided, may we text your cell for contact?
YesNo

Owner's Email*

Patient Information

Name*

Species*
DogCat

Breed*

Color

Age (Yrs. or Mos.)*

Sex*
MaleFemale

Spayed/Neutered?*
YesNo

If your pet is a Cat, does your Cat go outside?
YesNo

Is your pet known to be aggressive to people or other pets?*
YesNo

List Injuries, Exposure to toxic substance, previous medical problems, or any surgeries

In your own words, what is your pets problem (Symptoms)?*

Primary Care Veterinarian's Name Primary Care Veterinarian's Address Primary Care Veterinarian's Phone

I do not wish to have my pet’s name and/or picture displayed on our website, Facebook, or any other printed or electronic media.

Method of Payment Used*
CashCheckVisaMaster CardDiscoverAmerican ExpressCare Credit

Driver's License # (Present for Verification)
State Expiration

Social Security Number

Employer's Name Employer's Address May we call you at work? YesNo If Yes, Best time?

THANK YOU VERY MUCH FOR YOUR TIME AND CONSIDERATION IN THIS MATTER!