Binder Animal Hospital

2941 Telegraph Road
Saint Louis, MO 63125

(314)892-5406

binderanimalhospital.com

New Client & Patient Information

PLEASE CALL TO MAKE AN APPOINTMENT BEFORE FILLING OUT THIS FORM
CLIENT INFORMATION
Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
Phone
Phone TypePhone Number
Phone
Phone TypePhone Number
E-Mail Address
E-Mail Address (required) :
Emergency Contact Information
Emergency Contact Name:

Emergency Contact Phone:

Were we recommended by someone?
Name

PET INFORMATION
Pet's Name (required)

Selection (required)

Dog
Cat
Other


Breed: (required)

Color: (required)

Date of Birth: (required)

Please Select: (required)

Male
Male Neutered
Female
Female Spayed


Is Your Pet Microchipped? (required)

Yes
No


Are Vaccines Current? (required)

Yes
No


Previous Veterinarian
Previous Veterinarian's Name:

Previous Veterinarian's Phone:

Medications
Pet's Current Medications: (required)

Diet
Pet's Normal Diet: (required)

Visit
Reason for Visit: (required)

OTHER INFORMATION
May we release records if necessary? (i.e. groomer, boarding kennel, classes, other veterinarian) (required)

Yes
No


May we post your pet's picture on our Facebook site? (required)

Yes
No


Method of Payment (required)
Cash
Check
Credit Card
Debit Card
Care Credit
AUTHORIZATION

I hereby authorize the veterinarian to examine, treat, or prescribe for the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that all charges will be paid for at the time of the service. I recognize that a deposit may be required for surgical treatment or hospitalization. If paying by check and my check is returned unpaid, I authorize an electronic debit of my account for the check amount and all applicable service fees, taxes, and related expenses permitted by law.
(I certify my typed name below as my electronic signature)
Signed: (required)


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