Have you ever brought any pets to Highlands Animal Clinic before?* Have you ever brought any pets to Highlands Animal Clinic before?* Yes No

Owner's First Name*

Owner's Last Name*

Street Address*

Street Address Line 2

State*

City*

Postal/Zip Code*

Primary Phone Number*

Owner's Email*

Do you already have a scheduled appointment? Do you already have a scheduled appointment? Yes - Online Yes - Called No

Spouse/Partner's First Name

Spouse/Partner's Last Name

Spouse/Partner's Phone Number

Pet's Name*

Species* Species* Dog Cat Other

Date of Birth/Age*

Breed*

Color*

Sex* Sex* Male Female Male Neutered Female Spayed

Primary Reason for Visit to Highlands Animal Clinic*

Previous Veterinarian

How did you hear about us?

Do we have permissions to use photos of your pet(s) on Facebook, Instagram, and our Website? * Do we have permissions to use photos of your pet(s) on Facebook, Instagram, and our Website? * Yes No

I understand that I am responsible for services and for all charges incurred in the care of my pet. I further understand that that these charges will be paid at time of services. Payment types that are accepted by Highlands Animal Clinic are Visa, Mastercard, Discover, American Express and CareCredit. We do not accept personal checks and do not offer any in house payment plans.* I understand that I am responsible for services and for all charges incurred in the care of my pet. I further understand that that these charges will be paid at time of services. Payment types that are accepted by Highlands Animal Clinic are Visa, Mastercard, Discover, American Express and CareCredit. We do not accept personal checks and do not offer any in house payment plans.* I Understand