Please fill in the form below. Which clinic will you be visiting primarily * Advanced Animal Care (Richmond) Advanced Animal Care (Berea) Locust Trace Veterinary Clinic (Lexington) Waco Animal Hospital (Waco) Location NoneAdvanced Animal Care BereaLocust Trace Veterinary ClinicWaco Animal HospitalAdvanced Animal Care Full Name Prefix First Name Last Name Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Country - None -AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone Number Area Code Phone Number E-mail Driver's License Number * How did you hear about our practice? Word of Mouth Google Search Social Media Phonebook Billboard Print Ad Other Other Pet Information Pet's Name * Species * Breed (If applicable) Sex * Male (Not neutered) Female (Not spayed) Male (neutered) Female (spayed) Age * Date of last vaccination Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20102011201220132014201520162017201820192020 I, being responsible for the described animal, have the authority to grant my consent to receive, prescribe and treat my pet. Further, I accept full financial responsibility for authorized medical treatments. I also authorize Advanced Animal Care to fax my animal's records to my regular veterinarian Please Sign Below Signer Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Authorization Client Agreement: I understand that AAC utilizes the services provided by the Madison County Attorney for returned checks and all accounts sent to the county attorney are subject to additional fees and penalties. I also understand any balance that remains unpaid for any reason will be sent to a professional collection agency and I agree that I will be responsible for additional fees and penalties incurred to Advanced Animal Care for collections on this account, as well as interest accrued at 1.5% monthly (18% annum). Advanced Animal Care reserves the right to present past due accounts to small claims court in place of a collection service. I have read the above and understand the hospital payment policy. I acknowledge that I am the responsible owner of the pet(s), or authorized agent of the owner, associated with the below named pet(s) and represent all other owners. I assume responsibility for all charges incurred in the care of the animal. You must be 18 years or older to legally sign this consent. All fees are due at the time services are rendered. AAC does not offer payment plans, but clients may apply for Care Credit. I agree I agree AUTHORIZATION FOR RELEASE OF RECORDS Under Kentucky law, we must have a release signed by you before any information regarding your pets can be released to others. Please indicate below if you have anyone that you know will need information regarding vaccination history, pet's health status, etc. Please note if your pet is hospitalized only people listed in this form can call and check on the animal. PLEASE NOTE, only the OWNER and CO-OWNER is authorized to make decisions regarding the health care of your pet. Co-Owner(s) Dependent(s) Regular Vet Regular Groomer/Trainer I authorize * I AUTHORIZE Advanced Animal Care to use my pet(s) photo for social media or clinic use. ("Like" us on Facebook or "Follow" us on Twitter) I DO NOT AUTHORIZE Advanced Animal Care to use my pet(s) photo for social media or clinic use. I have verified that all information above is true Please Sign Below Signer Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022
