FFAH New Client Welcome Form

Welcome!
We are pleased to welcome you to our hospital. Please take a few minutes to fill out this form as completely as you can. We look forward to working with you in maintaining your pet’s health.
Client Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2 (including apartment or other unit #)

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Spouse or Co-Owner Name

First NameLast Name
Spouse or Co-Owner Phone

Area CodePhone Number
Spouse or Co-Owner E-mail
example@example.com
Are you employed by the military or are you a first responder (Police, Fire, EMS)?

YesNo
Do you plan to use Woof's Play & Stay for your boarding or daycare needs?

YesNo
How did you hear about us?*
If you selected "Friend" above, who can we thank?

First NameLast Name
Pet Details:
Name:*
Species:*

DogCatOther
Breed:*
Color/Markings:*
Date of Birth (if known) or Approximate Age:*
Gender*

FemaleFemale SpayedMaleMale NeuteredUnknown
Is your pet up to date on heartworm prevention?

YesNo
Is your pet up to date on flea/tick prevention?

YesNo
Please list any medications your pet is currently taking:
Including over-the-counter, supplements, preventatives, etc.
Briefly describe any past illnesses or surgeries:
Do you or your pet have any allergies (including vaccine reactions) we need to know about?
We use all sorts of treats during appointments, including some containing peanuts - please tell us what to avoid!
Do you consent to us offering your pets these treats during their appointment?

Kong paste (multiple flavors)Biscuit-type treatsChuru (cats; tuna and/or chicken)Baby food (meat flavors)Hydrolyzed treats onlyOwner-provided treats onlyNo treats at allOther
Name and phone of previous vet we can request records from?
Kansas State University VHC will not release records to us directly - you must contact them at 785-532-5690 and request they be sent to us at furfamilyah@gmail.com
If you have digital copies of records, please upload them here:

Browse Files

Cancelof
If you would like, please upload a picture of your pet (showing their full face) to use for their record here:

Browse Files

Cancelof
Social Media Release:
I grant to Fur Family Animal Hospital, its representatives, and employees the right to take photographs and/or video of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Fur Family Animal Hospital may use such photographs and/or videos of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, and Web content.
Initial to Accept:
Vaccine Informed Consent:
Although the benefits of pet vaccination far outweigh the risks, certain events, some potentially fatal, can be associated with vaccinations. It is impossible to predict which pets are prone to vaccine reaction. If you are aware of a reaction your pet has had in the past, please inform the doctor. Some adverse reactions which may be associated with vaccinations are fever, soreness at the injection site, sore joints, vaccine site lumps, vaccine site tumors (cats only), and anaphylaxis (hives, facial swelling, vomiting, respiratory distress, collapse).

I have read and understand the materials provided to me. Any questions about vaccinations have been answered to my satisfaction. I am aware of the potential benefits and risks of vaccinating my pet. I understand that my signature represents my request to have my pet vaccinated and releases Fur Family Animal Hospital and its agents of any liability.

I, being of legal age and owner of the above animal, have the authority to grant Fur Family Animal Hospital and its agents my consent, and I hereby give such consent to vaccinate the animal named above.
Type Full Name to Acknowledge*
First and Last Name
Payment:
We will gladly prepare a written estimate of services for every appointment. All professional fees are due at time services are rendered. In cases of extensive medical or surgical procedures where full payment may be difficult at discharge, we accept major credit cards or can establish a payment agreement through Scratch Pay if approved in advance of treatment. Checks are not accepted without prior authorization. There will be a service charge of $25 for any check returned unpaid.

To prevent the spread of infectious diseases, all hospitalized (including dropped off) patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventive care and the appropriate charges will be assessed on the discharge invoice.
Type Full Name to Acknowledge*
First and Last Name
Release of Records:
Do you authorize Fur Family Animal Hospital to release the above mentioned pet's records if requested by another veterinary facility, boarding/grooming/daycare service, human or pet insurance company, or other organization such as pet adoption agency?

YesNo, please contact me firstNo, with the exception of vaccination and preventative care due dates
Cancellation Fees:
Cancelling an appointment with less than one business day's notice or not showing up to your appointment with no notification (No Call/No Show) will result in a $25 (one pet) or $50 (multiple pets) last minute cancellation fee. This fee will be required to be paid in order to reschedule the appointment.

Monday appointments must be cancelled by Friday morning.

If you are excessively late to your appointment and we are unable to accomodate you, the fee will be assessed. ***Please call even if you are running late - we will do our very best to still have your pet seen that day.***

Multiple incidences of "No Call/No Showing" will result in your appointments being made on a drop off only basis.
Type Full Name to Acknowledge*
First and Last Name
Should be Empty:

Client Details:

Pet Details:

Social Media Release:

Vaccine Informed Consent:

Payment:

Release of Records:

Cancellation Fees: