"*" indicates required fields 7826 Saint Andrews Church Road Louisville, KY 40214 Telephone: 502-935-4799 Fax: 502-935-9897 Welcome to All About Pets. Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill in this form completely. Thank you! Owners Name* Date of Birth: MM slash DD slash YYYY Spouse/Other Date of Birth: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home Phone#Work#Cell#Email Where did you hear about us or who were you referred by? SS#/SIN Driver’s License# Employer: Reason for visitPlease list any additional persons that may bring your pet in the event that you are unavailable. Understand that these persons will have the authority to make decisions for your pet both medically and financially. If someone other than the persons listed below brings your pet in, it may be necessary to pause treatment until a listed party is contacted for approval.NamePhone Number Add RemoveYour Pet(s):NameDOBSpeciesBreedSexNeutered/SpayedColorMarking Add Remove SMS Communication Consent You can choose to receive reminders for upcoming services that are due, appointment reminders, medication refill reminders, online pharmacy info, etc. from All About Pets Animal Hospital through email and/or text message. You can opt out of this service anytime by unsubscribing to emails, replying "STOP" to text messages, or reaching out to the clinic directly.* I consent to the use of SMS messages and/or email communication. I DO NOT consent to the use of SMS messages and/or email communication. Medical Records Release Your pet's medical records are protected information. However you can choose to allow us to share your pet's records to those with a professional relationship to you and your pet in advance of a formal request. This would apply to boarding facilities, training facilities, "daycare," other veterinary hospitals, emergency centers, etc. If you choose to decline no records will be released to any requesting party without your written consent. (Written permission will always be required to share records to any party outside of a professional relationship. Ex.: Pet is re-homed and new owner would like previous records.)* I consent to the release of my pet's records without my written consent. I DO NOT consent to the release of my pet's records without my written consent. Image Usage Release Occasionally we may share a pet's image on our facebook page, advertising, newletter, etc. You can choose whether you would like your pet to be eligible. You can revoke this permission at any time, but understand that if your pet's image has already been used it cannot be removed.* I consent to the use of my pet's image. I DO NOT consent to the use of my pet's image. Cancellation Policy We understand that life happens, and sometimes appointments need to be cancelled or rescheduled. We kindly request that a call is placed to notify our office if you will be unable to make your appointment. In the event of multiple “No Shows” you may be required to place a deposit on your account to secure future appointments. This deposit may be forfeited if the scheduled appointment is not kept without notifying our office. I hereby authorize Dr. Jennifer Connelly to examine, prescribe for, and/or treat the above pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time of release. Signature of Owner/AgentDate MM slash DD slash YYYY * Note: We do not accept American Express. * We will no longer be accepting checks from Wood Forest Bank. Thank you for choosing All About Pets Animal Hospital!