Owner's Information

Are you the owner of this cat(s) or dog(s)? *

Yes
No

(If you answered “No” and you are not currently here for an appointment, please give us a call. If you are already here for your appointment, please let one of our team members know that you are not the owner.)

Have you made an appointment already? *

Yes
No

Please note: We will not contact you for an appointment. You need to call us to schedule an appointment. This form is not an appointment request. Please give the office a call at 352-688-9911.

If yes, what date is your appointment scheduled for? *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Secondary Phone Number

Spouse/Co-Owner's Name

First

Last

Spouse/Co-Owner's Phone Number

Email *

(For appointment confirmations, reminders, etc.)

Driver's License Number *

Name of previous veterinarian *

Phone number of previous veterinarian *

Preferred Method of Contact (select all that apply) *

Text
Email
Call

**Standard text messaging rates may apply from your carrier.**

How did you first hear about Kind Animal Care? Please check all that apply *

Whom may we thank for the referral? *

Please specify which online source *

If other, please specify *

Pet's Information

Pet's Name *

Species *

Dog
Cat

Does your pet have a microchip? *

Yes
No

Age/Date of Birth *

Breed *

Color *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is it okay to post a photo of your pet on our Facebook or Instagram account? *

Yes
No

Would you like to add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Does your pet have a microchip? *

Yes
No

Age/Date of Birth *

Breed *

Color *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is it okay to post a photo of your pet on our Facebook or Instagram account? *

Yes
No

Would you like to add another pet? *

Yes
No

Pet's Name *

Species *

Dog
Cat

Does your pet have a microchip? *

Yes
No

Age/Date of Birth *

Breed *

Color *

Sex *

Male
Male (netuered)
Female
Female (spayed)

Is it okay to post a photo of your pet on our Facebook or Instagram account? *

Yes
No

Financial Policy

Please read our financial policy carefully prior to signing it.

Our policy is to provide you with a written medical treatment plan of fees required for in-clinic treatment, emergency care, surgery, and/or hospitalization. A deposit is required prior to any treatment and for all hospitalized animals. Full payment is due at time of services. Hospital accounts must be kept current throughout the period of hospitalization. If you do not pick up your pet within 10 (ten) days of its release date, your pet will be considered abandoned. Your total bill, which is to include the treatment charges plus the ten additional days of hospitalization will be turned over to a national collection bureau, to be placed on your credit record.

ur policy is to provide you with a written medical treatment plan of fees required for in-clinic treatment, emergency care, surgery, and/or hospitalization. A deposit is required prior to any treatment and for all hospitalized animals. Full payment is due at time of services. Hospital accounts must be kept current throughout the period of hospitalization. If you do not pick up your pet within 10 (ten) days of its release date, your pet will be considered abandoned. Your total bill, which is to include the treatment charges plus the ten additional days of hospitalization will be turned over to a national collection bureau, to be placed on your credit record. *

I have read and understand

Desired Form of Payment (please check all that apply) *

**If using Care Credit card, card holder must be present at the time of payment. **

I have read and understood the above policies and request treatment for my pet in accordance with these policies. I assume all financial responsibilities for all charges incurred to the patient (pet) and agree to pay all costs of collection and/or fees in the event of non-payment. *

I have read and understand

Signature *

Date *

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