Contact InformationOwner's Name:* Mr.Mrs.MissMs.Dr.Prof.Rev.Mx.None Prefix First Last Authorized Person(s) to act on my behalf (must be 18 years of age or older): Mr.Mrs.MissMs.Dr.Prof.Rev.Mx.None Prefix First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone:*Secondary Phone:Text message number:*Email:* Pet's InformationPet's Name (patient):* First Age/DOB:*Species:*FMC does not currently see exotics or 'pocket pets.' Dog Cat Sex or spay/neuter status:* Intact male (not neutered) Altered male (neutered) Intact female (not spayed) Altered female (spayed) Breed:*Color/markings:*Approximate weight:*Does this pet have any existing medical conditions or medications?* Yes No Please describe the conditions and medications:*Has this pet ever had any allergies, drug sensitivities, or vaccine reactions?* Yes No Please describe:*Has your pet been known to bite or show aggression?* Yes No Please describe:*Has this pet ever been vaccinated for rabies?* Yes (Must provide proof) No (My pet will need the rabies vaccination required by CT State Law) Unsure (My pet will need the rabies vaccination required by CT State Law) You will need to provide a rabies certificate from the veterinarian who gave the vaccine. Drop files here or Select files Max. file size: 256 MB. The State of CT requires all dogs and cats maintain a current rabies vaccine to help protect them and the public health. Without a certificate to prove they are current, we will need to vaccinate your pet for rabies.Has your pet been to a veterinarian before?* Yes No Please provide the name and contact information for any veterinarians your pet has seen.*Please upload any medical records you have from previous veterinary visits. Drop files here or Select files Max. file size: 256 MB. Do you authorize us to contact this/these veterinarian(s) to receive copies of the medical records of your pet(s)?* Yes No Reviewing your pet’s prior medical records will give us the best chance to help your pet. If you do not want us to contact your veterinarian, please upload your pet’s complete medical records here. Drop files here or Select files Max. file size: 256 MB. Policies** We accept cash, Visa, Mastercard, American Express, and Discover. **we do not accept checks** * We will treat you with courtesy and respect and we expect the same in return. * A deposit is required. If you cancel with less than 48 hours’ notice, fail to come to your appointment, or arrive after your appointment start time, your deposit is charged as a missed appointment fee and a new deposit is required to schedule a new appointment. * A few days prior to your appointment, we will call you to confirm your visit. We need to hear back from you in order to confirm. If you do not respond to our request to confirm at least 24 hours before your appointment, your appointment may be canceled and you will forfeit any deposit or pre-payment, so we can assist other patients who are waiting. * Send your pets’ rabies certificate and medical records to us at least 24 hours before your visit. We need to review these records ahead of time to assist in our care for your pet(s). If we do not receive the records ahead of time, we may not be able to examine your pet(s) and your deposit will be charged for your appointment. * Arrive ~10 minutes before the start of your appointment. Because we are trying to serve so many pets in need, if you arrive after your appointment start time, we cannot guarantee we will be able to see you. This will be considered a missed appointment, and your deposit will be charged as your missed appointment fee. * During your appointment our team can provide you with an estimate for recommended services. Please let us know if you would like an estimate or have any financial limits so that we may try to work within your budget. * Sharing the good work of CHS and our Clinic is key to inspiring the community to support this program and make it available for pets in need. CT Humane Society and Fox Memorial Clinic may use photos of your pet(s) and their name(s) for this purpose. We will not use confidential owner information, like your name, without your consent. I agree to abide by the policies.Authorizations: Please tick the check boxes for the following statements or answer the questions.I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume responsibility for all charges incurred in the care of my animal. I also understand all professional fees are due at the time services are rendered.* I agree I give CHS permission to use my first name if my pet is selected to be featured in a story:* Yes No I give CHS permission to use my first and last name if my pet is selected to be featured in a story:* Yes No I attest that the above pet(s) is owned by me, and I authorize the CT Humane Society and Fox Memorial Clinic to release any medical records upon request by myself or a veterinary hospital.* Yes No Ticking the checkbox below serves as my signed agreement to and understanding of all of the policies, requirements and statements as indicated above and in Fox Clinic program guidelines.* I agree and understand Today's Date:* MM slash DD slash YYYY CAPTCHA
