Contact Information

FIRST NAME: *
LAST NAME: *
SPOUSE'S NAME:
ADDRESS 1: *
ADDRESS 2:
CITY: *
ZIP: *
TELEPHONE - Home: *
TELEPHONE - Cell:
TELEPHONE - Work:
TELEPHONE - Spouse:
EMAIL: *
DRIVER'S LICENCE #: State:
HOW DID YOU HEAR ABOUT US?: -please select one- Ko'olau Pets Pets Discount Family Friend Other - please specify   Other:

Pet #1

PET NAME:
BREED:
COLOR:
TYPE OF PET: Dog   Cat   Bird   Other, please specify
BIRTHDATE:
SEX: Male   Female
SPAYED/NEUTERED: Yes   No
MICROCHIP?: Yes   No
MICROCHIP #:

Pet #2

PET NAME:
BREED:
COLOR:
TYPE OF PET: Dog   Cat   Bird   Other, please specify
BIRTHDATE:
SEX: Male   Female
SPAYED/NEUTERED: Yes   No
MICROCHIP?: Yes   No
MICROCHIP #:

Pet #3

PET NAME:
BREED:
COLOR:
TYPE OF PET: Dog   Cat   Bird   Other, please specify
BIRTHDATE:
SEX: Male   Female
SPAYED/NEUTERED: Yes   No
MICROCHIP?: Yes   No
MICROCHIP #:

Terms & Conditions

I herby authorize the staff of Haiku Veterinary Clinic to render any treatment which is deemed necessary to my pet(s) health while in the custody of the hospital. I understand that in the event of unusual emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone.

I understand that professional fees are to be paid at the time of service rendered and a deposit is required for all pets admitted to the hospital.

I (We) authorize HVC to obtain my pet(s) previous veterinary records from: