Weddington Animal Hospital
13667 Providence Road
Matthews, NC 28104
www.WeddingtonAnimalHospital.com
wahcares@windstream.net
Thank you for entrusting us to care for all of your pets' needs.
Please print out this form and fill out the information below so that we can get to know you and your pet better.
Client Information:
Name:___________________________________________________________ Date:____________________
Address:__________________________________________________________________________________
Home Phone:____________________Cell Phone:______________________Work Phone:__________________
Email Address:____________________________________________________________________________
* We ask for an email address so that we can send you reminders. We do not share any information. *
Secondary Name:___________________________________________________________________________
Secondary Cell Phone: _________________________________ Secondary Work Phone: __________________
Best number/Person to call: _________________________ Best time to reach you: ________________________
How did you learn of our hospital?
Drove By ____ Yellow Pages ____ Previous Client ____ Web Page ____ Personal Recommendation ____
If recommended by someone, whom may we thank? _______________________________________________
Patient Information:
Pet's Name__________________________________ Dog ____ Cat ____ Other ________________________
Date of Birth/Age ________________________ Male ____ Female ____ Spayed/Neutered ____ Microchip ____
Breed ___________________________________________ Color/Markings: ___________________________
Vaccine History - Please check all that your pet has recieved within the last year:
Dog:
Rabies (1 or 3 yr) ____ Distemper/Parvo (DA2P) ____ Bordetella ____ Porphyromonas (Dental) ____ Lepto ____ Heartworm Test ____
Cat:
Rabies (1 or 3 yr) ____ Distemper (FVRCP) ____ Leukemia (FelV) ____ Feline Leukemia & Aids Test (FelV/FIV) ____
*If you have a copy of your pet's medical history and labwork, please bring it with you for our records*
Prior and/or current medical problems _____________________________________________________
Prior Surgeries ___________________________________________________________________________
Special Diets _____________________________________________________________________________
Current Medications _______________________________________________________________________
Allergies (vaccines, medications, environmental) __________________________________________
Previous Veterinarian (Name and Phone Number) _____________________________________________
Preferred payment method: Cash ____ Check ____ Debit ____ MasterCard/Visa ____ CareCredit ____
**** All fees are due at the time services are rendered. ****