Primary Owner's Phone Number *

We will use this number first for any information about the patient.

(###)

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Spouse/Significant other 's Phone Number (Secondary phone number)

We will use this number if we are unable to contact someone at the primary owner's number.

(###)

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Owner's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this age known or an estimated age? *

Date of birth is known

This age is estimated

Is the patient any of the following *

Choose all that apply

Family Pet

Hunting/Working

Agility

Show

Therapy/Guide

Law enforcement/Military

Date of first clinical sign (or approximate duration). *

MM

DD

YYYY

Acute or Slow Onset? *

Acute

Slow Onset

Progression

Getting Worse

Getting Better

Staying the Same

Intermittent

Environment: *

Indoor

Outdoor

Indoor & Outdoor

Fence

No Fence

Not applicable

Rabies *

MM

DD

YYYY

Treatment Authorization *

I am the owner for the animal named above, and I am 18 years of age or older. I agree to be physically present during the initial exam and consultation. If any other person(s) has claims of ownership on this pet I acknowledge that I have advised them to also be present for this initial exam and consultation - or - they have given me full authorization to make medical decisions for this pet on their behalf. I give permission for Dr. Montgomery and staff of Davis Animal Hospital to examine and treat my pet as I have requested. I understand that payment is due when services are rendered. The consultation fee is $135 and is due at the time of the appointment. Any additional diagnostics will be discussed at the time of the appointment and payment will be due for those diagnostics at that time. We accept cash, check, AMEX, Visa, Discover, and Mastercard. We offer financing options through Care Credit (6 month deferred interest), Wells Fargo (6 month & 9 month deferred interest), and Scratch Pay. These payment plans should be applied for using the "financial assistance" link found on the bottom of our website prior to the appointment time.

I understand and agree and I will be physically present with my pet during the initial exam and consultation.