• Client-Patient Information Form

    Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a few moments to complete each of the information sheets.
  • Date Format: MM slash DD slash YYYY
  • Emergency Contact:
  • (Number to contact)
  • Animal Information/Medical History

  • NameSpeciesBreedColor
  • Age/ DOBSexSpayed/Neutered
  • Prior Illness:Prior surgery not including altering:Date of last Vaccines & Clinic done at:
  • NameSpeciesBreedColor
  • Age/ DOBSexSpayed/Neutered
  • Prior Illness:Prior surgery not including altering:Date of last Vaccines & Clinic done at:
  • NameSpeciesBreedColor
  • Age/ DOBSexSpayed/Neutered
  • Prior Illness:Prior surgery not including altering:Date of last Vaccines & Clinic done at:
  • Notification/ Agreement

    To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the Animal Clinic of Michigan City to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify Animal Clinic of Michigan City in writing on the contrary.
  • Authorization for release of medical records.

    I authorize the Animal Clinic of Michigan City to acquire any and all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them
  • Appointment Cancellation/ Late & Reschedule Policy Agreement

    Animal Clinic of Michigan City is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen.
  • Please call us at 219-879-0249 by 3:00pm on the day prior to your scheduled appointment to notify us of any changes or cancellations. To cancel on a Monday appointment, please call our office by 3:00 pm on Friday. If prior notification is not given, you will be charged $25.00 for the missed appointment.

    If you are more than 15 minutes late to your scheduled appointment you will be responsible for a $10.00 late fee and will be seen as a work in (work in can mean anytime from your original appointment to the time we close).

    If you are more than 20 minutes late to your scheduled appointment you will need to reschedule and will be charged a $25.00 service charge.

  • PHOTO CONSENT

    I grant to Animal Clinic of Michigan City, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that Animal Clinic of Michigan City may use such photographs of me and or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.