Name: West Ballantyne Animal Hospital
Address: 11926 Providence Road West, Charlotte Ste E0 Charlotte, NC, 28277, United States
Telephone: (980) 222-1709

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Client Information
Primary Pet Owner Name*
First Last
Contact Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer*
Secondary Pet Owner Name
First Last
Contact Number
Emergency Contact*
First Last
Contact Number*
How did you hear about us?*
Who may we thank?
First Last

Patient Information
Pet's Name*
First
Species*
Breed
Color/Markings*
Sex*
Spayed/Neutered?*
Age*
MM
DD
YYYY
How long have you owned your pet?*

Pet Information Continued
Previous Veterinarian*
Please list any known medical conditions.*
Please list any known allergies.*
Current medications*
Special/Prescription diet
Kennel or Groomer
First Last
Is there any other important information you would like us to know about your pet?
Instructions
We ask that services be paid at the time services are rendered. At this time, our hospital does not offer any payment plans or deferred billing. We routinely provide estimate for recommended treatment plans but please ask if costs are unclear. A deposit is required for any hospitalized patient. We accept the following forms of payment: cash, personal check, Care Credit and credit/debit including Visa, Mastercard, Discover, and American Express. All unpaid invoices will incur a processing charge of 1.5% after 30 days.

*Please note that when writing a personal check, a copy of a valid driver’s license will be needed for processing. There is a $35.00 fee for a returned check in addition to the fees that your bank may charge*

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

To help prevent the spread of infectious disease, we require that all hospitalized and surgical patients are current on the following vaccines. You must provide proof that your pet is currently up to date. Canine: Distemper/Parvo, Rabies, Bordetella Feline: Distemper, Rabies
Today's Date*
Date Format: MM slash DD slash YYYY
Signature (Enter Full Name Here)*

11926 Providence Rd. West, Charlotte NC 28277

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Client Information

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Pet Information Continued

Instructions