Please fill out and submit the form below before your first appointment. Items marked with a (*) are required.

Today's Date:*

OWNER INFORMATION

Owner's Name*

Street Address*

City*

State*

Zip Code*

Cell Phone Number*

Other Phone Number

Your Email*

Employer

Work Phone

Best Form Of Contact*
PhoneTextEmail

We accept cash, Care Credit, debit cards, Visa, MasterCard, American Express, and Discover Cards. WE ARE SORRY, PERSONAL CHECKS CANNOT BE ACCEPTED FOR FIRST TIME CLIENTS.

What is your preferred method of payment?*

Emergency Contact Name*

Emergency Contact Phone*

How did you hear about us?

PET INFORMATION

Pet's Name*

Age*

Type*

Breed

Color

Sex
MaleFemale

Spayed/Neutered?
YesNo

Birthdate

Micro-chipped?
YesNo

Current medications your pet is taking

Anything else we need to know?

AUTHORIZATION
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 the animal. I also understand that all professional fees are due at the time services are rendered.

Signature of responsible party:

Date

The information on this form is strictly confidential and is to be used only by this practice to provide care and treatment for your pet.

AT YOUR REQUEST WE WILL GLADLY DISCUSS COST OF SERVICES and/or PREPARE A WRITTEN ESTIMATE FOR RECOMMENDED PROCEDURES.

Check here if you DO NOT wish to have your pets name/picture displayed on our website, Facebook, or any other promotional materials:
I do not want my pet's name or photo featured on any promotional materials.

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Indian Street Animal Clinic would like our valued clients and patients to know our hours of operation while we take time off to spend Thanksgiving with our families and pets. We will be open through Wednesday, November 22nd at noon and reopen on Monday, November 27th at 8am.

If you need any medication refills, or need to pick up food or any other products, please do not hesitate to give us a call or stop by before Wednesday at noon.

If you have an emergency while we are closed please call or visit either the Animal Emergency and Referral Center at 772-466-3441, located 1 mile north of Midway Rd at 3984 S. U.S. Hwy 1, Fort Pierce, or Pet Emergency of Martin County at 772-781-3302, located at 2239 S. Kanner Highway, Stuart.

From everyone at Indian Street Animal Clinic, we wish you a happy and safe Thanksgiving!!
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