ONLINE FORMS

TOTAL PET WELLNESS FORM
Please complete this form with your and your pet's basic information so that we may effectively and efficiently provide the service you deserve!

Pet & Human Information

* Indicates required field

Your Name *

First

Last

Pet's Name *

First

Last

Breed & Birthdate (Yr/Mo) *

How can we help? *

Phone Number *

Alternate Phone Number *

Email *

Physical Address *

Line 1

Line 2

City

State

Zip Code

Country

Please fill out a form for each pet.

*To help prevent the spread of infectious disease, ALL HOSPITALIZED patients MUST be current on all recommended vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be performed at the time of your appointment if not already current.
**I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize TOTAL PET WELLNESS to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the reverse side and any additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. Charges may be made for appointments if I do not cancel them prior to 24 hours before the appointment time. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. Should billing be approved for any services, all accounts unpaid after 30 days receive a $5.00 Billing Charge each month and a late charge computed at a periodic rate of 1.5% per month, which is an annual rate of 18%, with a minimum monthly charge of $1.00. I understand that veterinary service is provided during nighttime hours as necessary in the judgement of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within the agreed upon timeframe, I understand I will be charged a boarding fee. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, I understand TOTAL PET WELLNESS may assume the pet is abandoned and is hereby authorized to dispose of said pet as deemed best and/or necessary. Submission is approval of above.
>>Missed or cancelled appointments (<24 hrs) subject to cancellation fees.

I agree to receiving marketing and promotional materials *

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