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Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Pimary Phone*

Email Address*

Driver's License #

Spouse

First Last

Spouse Phone

Spouse Email

Pet's Name*

Species*

Canine

Feline

Breed*

Color*

Sex*

Male

Female

Neutered

Spayed

Birthdate*

Last Vaccs*

My pet(s) may be released to the following persons:*

I affirm that the above information is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes. I authorize the veterinary staff to perform all medical procedures necessary for my pet’s health. I assume full financial responsibility & agree to pay in full when services are rendered or upon discharge of the patient.

We recently instituted a non-refundable deposit requirement of $79 for all initial appointments, which be refunded at the time of your appointment. This deposit is necessary because of an increasing number of no shows and last-minute cancellations. We hope to reduce the number of empty appointment slots and offer them to other pets in need.

We accept Cash, Local Bank Checks, MasterCard, Visa and Discover for your convenience.

Signature*

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