Owner's Name *
Pet's Name *
Type of Pet *
If Other, please list
Breed
Gender
Is your pet neutered/spayed *
Pet's colorings/markings *
Pet's Age *
Pet Photo
Does your pet have a history of reactions to vaccines?
Does your pet have a history of reactions to medications?
Does your pet have a history of reactions to food?
What medications is pet on?
What supplements?
What heartworm is your pet taking ?
If other heartworm medication, please list
What flea medication is your pet taking?
If other flea medication, please list
Why does your pet need to be seen? Please describe the symptoms? How long? *
What brand of food do you feed? *
How much food do you feed your pet each day? *
How much exercise does your pet get? *
Describe your pets average day
Please have your current vet fax your pets records to 843-769-6715 or email them to This email address is being protected from spambots. You need JavaScript enabled to view it. at least one day prior to your first appointment.
Special notes about your pet *
BY SUBMITTING THIS FORM, I AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIME OF DISCHARGE. I ALSO AGREE TO PAY ANY FEES INCURRED FOR COLLECTION OF SAID CHARGE. I UNDERSTAND THAT FEES MAY VARY DEPENDING ON THE NATURE OF MY PETS CASE AND THE REQUIRED CARE AND TREATMENTS. AS A RESULT, ESTIMATED FEES MAY BE RAISED OR LOWERED. I UNDERSTAND THAT BEES FERRY VETERINARY HOSPITAL IS OFFERING A VARIETY OF TREATMENT OPTIONS, INCLUDING HOLISTIC AND ALTERNATIVE OPTIONS. BY AUTHORIZING ANY TREATMENT THROUGH CONSENT AND/OR PURCHASE, I RELEASE BEES FERRY VETERINARY HOSPITAL AND ITS AGENTS FROM ANY LIABILITIES. I UNDERSTAND THAT PICTURES AND VIDEOS OF MY PET MAY BE USED FOR BEES FERRY VETERINARY HOSPITAL RECORDS AND PUBLICITY BUT WILL NEVER BE SOLD, TRADED OR USED FOR OTHER REASONS. *
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