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White Oaks West
Pet Chat, Veterinarian in Springfield IL White Oaks West Springfield IL White Oaks West Springfield IL

Registration and Medical History Form | Exotic Pets

PERSONAL INFORMATION

   

   

Address (Street/apt/):

Zipcode / City / State:

Your Place of Employment (Employer / Title):

Your Work Phone#:

List any children's names and ages:

Spouse Full Name:

Spouse Phone Number:

Spouse's Employment (Employer / Title):

Spouse Work Phone#:

How did you find out about our Hospital?


PET INFORMATION

Pet's Name:

Species:

When Did You Acquire Your Pet:

Where did you acquire your pet?:

Age? (Approximate Age?)

Sex (Select Spay/Neuter if applicable):

Color:

Describe all foods, including the BRAND and the AMOUNT that you are feeding daily: (seeds, pellets, fruit...):

Describe all vitamin and mineral supplements, including the BRAND, and how much/often administered:

Please list any other pets (Name and Species):


Previous Medical Conditions:

Is there any previous medical history (if so please give the name of the veterinarian so we can call for records)?

List any major medical issues/surgeries this pet has had throughout it's history?

List the names of any medications that your pet is currently taking and how much/often they are given:


Describe the enclosure as follows:

Type and size of enclosure:

Is pet housed alone or with any other pets?

Substrate:

Lighting:

Do you already have an appt scheduled? If so, what time/date?

If you have a medical concern that needs to be addressed, it is best to call to schedule an appointment.:

Briefly explain the reason for the appointment request:


I do further agree that should any payment become overdue more than five (5) days from the above agreed time of payment or payments, the entire balance shall be considered in default and become due and payable with interest finance charges from the date of default at the rate of one and one half percent (1-1/2%) per month, which is an annual percentage rate of eighteen percent (18%) applied to the previous balance without deducting current payments, and with the addition of any or all collection agency and/or attorney fees necessary to collect the full amount due to White Oaks West Animal Hospital without any relief whatever from Valuation or Appraisement Laws. I further agree that if my account becomes past due and is turned over for collection there will be a collection fee of 40% of the outstanding balance added for which I will be liable for.