Name, Address, and Contact Information

Primary Contact Information

Names of others who may bring animals to appointments

Animal Care Clinic understands that it may be difficult to personally bring your pet to their appointment. Therefore, we would like the names of any spouse, caregiver, or friend that may initiate treatment on your behalf. Leave blank if not applicable.



Animal Information

Please list your animals below. If you need more space, submit this form again with the additional animals.

First animal

Second animal



Medical History

If this is a first time visit, it is important that we receive all prior and appropriate medical history on your pet(s). This information could provide useful information in order to properly treat your pet. It is recommended that you contact your previous veterinarian and have information emailed to our office ( or faxed 406-632-5640 for records only.



Vaccination History

If “Yes”, you will need to provide a record of any prior vaccinations, along with any prior medical history. State law mandates that cats and dogs be vaccinated for the rabies virus. This clinic strongly recommends vaccinating against the Distemper Virus and Parvo Virus as both are highly contagious and extra precaution must be taken to prevent further contamination and infection of other animals.







A few more questions...


I understand that state law require the rabies vaccination for all cats and dogs
I also understand that clinic policy requires the Distemper vaccination and Kennel Cough (for dogs only).


I decline vaccination at this time because the required vaccinations are up-to-date with this clinic or have been given elsewhere. If my pet bites another animal or person while under the care of this clinic, I will provide proof of current rabies vaccination within 24 hours of notification of incident.


It is the owner’s responsibility to maintain control of their pet(s) at all times within Animal Care Clinic. All dogs must remain on a leash and be kept near the owner at all times. It is also the responsibility of the owner to give warning to Animal Care Clinic if their pet may be hostile toward people or other animals. If your animal should show aggression toward other animals or the staff, it is the right of Animal Care Clinic to restrain and apply a muzzle to your animal for personal protection. All cats and smaller animals must be transported within a cage, carrier, or similar restraint.


I am aware that my pet and my pet’s actions are my own responsibility as an owner


I have read and understand this authorization of service.


I am aware that this clinic is not staffed 24 hours a day.


I understand that payment in full is due at the completion of service.


I am the owner or agent of the above stated animal(s) and give the authority to execute this consent.