Client Information

Name_______________________________________Spouse/Other_________________

Address______________________________ City_____________ State____ Zip _______

Home Phone____________________ Work ________________ Cellular__________________ E-mail address (for reminders)

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

For your convenience we accept Care Credit, Visa, Master Card, American Express and Discover Card.

WE NO LONGER ACCEPT CHECKS

How did you discover our hospital? Hospital Sign Yellow Pages Client Referral Website Internet Word of mouth Facebook

Who may we thank for your referral?

Individual (Please provide name of individual.)___________________________________

Business (Please provide name of business.)_______________________________________

Patient Information

First Patient

Name_____________________________________ Species: Cat Dog Other

Breed________________________________________ Color____________________

Date of Birth or Approximate Age_________________________________________

Sex: Male Female Undetermined Spay or Neutered?: Yes No

Second Patient

Name_____________________________________ Species: Cat Dog Other

Breed________________________________________ Color____________________

Date of Birth or Approximate Age_________________________________________

Sex: Male Female Undetermined Spay or Neutered: Yes No

Please read the following and sign below:

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume 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 and that a deposit may be required for surgical treatment.

Client Signature:________________________________________ Date:___________