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Adair County Animal Hospital
Welcomes you and your pets!
Thank you for giving us the opportunity to care for your pet.
We’ll be happy to answer any questions you have about your pet’s health.
To insure the best care possible, please take the time to fill in this form completely. Thank You!
Owner’s Name __________________________________ Spouse/Co-owner __________________________
Address _______________________________City ____________________ State ________ Zip _________
Home Phone __________________Work Phone __________________Cell Phone _____________________
Driver’s License # ____________________ SS#/SIN __________________ Email _____________________
Employer’s Name & Address ________________________________________________________________
Spouse / Co-owner’s Employer & Address ______________________________________________________
It is best to call about your pet ... At what time _________________ At what phone # ___________________
In case of emergency please call ___________________________________ Phone # ___________________
Date ____________________________
PET HEALTH HISTORY
REGISTRATION
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 this animal. I also understand that these charges will
be paid at the time of release and that a deposit may be required for extensive or surgical treatment.
Signature of Owner ___________________________________________ Date ________________________
Method of Payment: Cash _____ Check _____ MasterCard _____ Visa _____ Other ___________________
2004 Campbellsville Road • Columbia, KY 42728
Phone: (270) 384-6113 • Fax: (270) 385-9174
Pet’s Name __________________________________Date of Birth _________________________
Type of Animal: Dog Cat Horse Cow Other ____________________________________
Sex: Male Female Neutered Spayed
Breed _____________________________ Color _______________________Weight___________
Vaccination History (Date of last vaccinations) __________________________________________
Current Diet: Dry Food Y / N Brand ___________________________________________
Canned Y / N Brand ___________________________________________
Human Food? Y / N Type ____________________________________________
Current Medications: _______________________________________________________________
______________________________________________________________
______________________________________________________________
Current Health Concerns: ____________________________________________________________
___________________________________________________________
___________________________________________________________
I am here today for
_____ Annual exam & vaccinations
_____ Illness in my pet
_____ Heartworm testing
_____ Microchipping
_____ Intestinal worm test
_____ Bath or Groom
*Check any that are of interest to you and we will discuss them.
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