VSEC Demographics Form

This form must be filled out completely before any treatment is rendered.

OWNER'S NAME:

First Last

Co-Owner/Spouse(If Applicable):

First Last

Address:

Street City State Zip

Telephone:

Home Work Cell

Who's Work #?

Driver's Licence Number: Are You Over 18? Yes / No

Place Of Employment:

Referring OR Regular Veterinarian:

Reason For Visit / Patient Problem:

Pet's Name: Species: Dog or Cat Breed:

Sex: Male or Female Spayed / Neutered? Yes or No Age: Color:

Are You the Owner? Yes or No If not, who is?

Does your pet mainly live:

Indoors

Outdoors

(Select One)

Has your pet been out of KS / MO within the last year?

Yes

(Select One)

Is your pet current and up-to-date on all vaccinations?

Yes

(Select One)

Can you supply a current rabies certificate?

Yes

(Select One)

Has your pet ever had a bad reaction to any medication?

Yes

(Select One)

If Yes, please list the medication(s):

Has your pet had any previous illness, injury, surgery?:

Yes

(Select One)

Have you ever brought a pet to this hospital before?

Yes

(Select One)

Has this pet been to our hospital before?

Yes

(Select One)

How did you hear about us? (Select all that apply)

Family/Friend

General Knowledge

Marketing Literature

Previous Visit

Vet

Website

Yellow Pages

PAYMENT POLICY: A deposit of 75% of the estimate is required prior to admission / hospitalization. Full payment for services rendered is required prior to discharge of your pet from the hospital, we do not bill. Please be advised that we participate with the Johnson County District Attorney's office in enforcing the Bad Check Laws. Consequently, we do not allow post dated or held checks. The Owner agrees to pay all charges for diagnostic, therapeutic, surgical, and preventative procedures. If paying or guaranteeing payment by credit card or debit card, the cardholder hereby specifically authorizes Veterinary Specialist & Emergency Center to automatically charge any outstanding account balance to the credit/debit card unless another form of payment has been prearranged. Any further outstanding balances will be turned over for collection and the owner will be responsible for any and all costs associated with the collection of debt. There will be a $30 fee assessed for all returned checks. By typing in your name below, you verify that you have read and understand the payment policy. This form is valid for one year.

Full Name: Signature Required at Checkin:

Payment Method(s):(Copy of ID Required)
•Care Credit •Cash •Check •Debit Card •Discover Card •MasterCard •Visa