www.SFAHospital.com - Hacienda Heights, CA

St. Francis Animal Hospital

15708 Gale Ave
Hacienda Heights, CA 91745

(626)968-4709

www.sfahospital.com

New Client Check In

Please make an appointment prior to filling out this form.

Thank you for your cooperation in letting us assist you.

New Client/ New Pet

Name *(required)*

First Name (required)	Last Name (required)

Spouse's Name

First Name	Last Name

Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Primary Number (required)
Phone Type	Phone Number (required)

Cell Phone Number (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

Owner's Date of Birth (required) :

Pet's Name (required)

Pet's Birth Date (or Estimated Age)

Type of Pet (required) :

Breed: (required)

Pet's Color

Sex: (required)

Male
Female

Is your pet Spayed or Neutered?

Yes
No

Are your pet's vaccines current? (required)

Yes
No
I Don't Know

Does your pet have any allergies? (required)

Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat my pet. I assume all 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 of this animal and that a deposit may be required for surgical treatment.
ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES.

By checking this box, you agree to the terms above. Please type your electronic signature below.

ELECTRONIC SIGNATURE

First Name	Last Name

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OUR HOURS

Day	Open	Close
Monday	8:00am	5:00pm
Tuesday	8:00am	5:00pm
Wednesday	8:00am	3:00pm
Thursday	8:00am	5:00pm
Friday	8:00am	5:00pm
Saturday	8:00am	12:00pm
Sunday	Closed	Closed

CONNECT WITH US

St Francis Animal Hospital

St. Francis Animal Hospital

New Client/ New Pet