We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions we’ll be glad to help you. We look forward to working with you in maintaining your pet’s health.
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Spouse or Co owner
How Did you learn about our practice?
Notify In Case of emergency
At What Age?
Where did you obtain this pet?
FriendBreederPet ShopHumane SocietyOther
At what age was the pet obtained
Pet's history--check (7) all that pet has received:
DHLP (Distemper--Dog)Feline leukemia test (Cat)Rabies (Dog/Cat)Parvovirus (Dog)FVRCP (Infectious diseases--Cat)Dentistry
G Prior illness
M Prior surgery
Reason for pet's visit :
Please mark (7) how you will be paying for your services today:
MasterCardAmerican ExpressCheck O VisaID DiscoverCashCare Credit
We will gladly prepare a written estimate of service fees if you desire (please ask our doctor or receptionist). All professional fees are due at the time services are rendered. There will be a service charge for any check returned unpaid.
To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice.
Signature of client responsible for pet(s)