Patient/Client Information Form

Date

Owner's Name

Spouse/Other

Address

City, State, Zip Code

Home Telephone

Work Phone

Cell

Employer Name & Address

Spouse/Other Employer & Address

Time to Call About Pet

Phone Number to Call About Pet

EMERGENCY Contact Name

EMERGENCY Contact Phone Number

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.
PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

How do you intend to pay?

Cash Credit Card

ANIMAL MEDICAL CENTER IS A FLEA FREE FACILITY. ALL ANIMALS ENTERING THE KENNEL WILL BE GIVEN A $6.50 CAPSTAR AT OWNER'S EXPENSE. TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED AND BOARDED ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL AND EXTERNAL PARASITES.

I authorize the doctor to provide vaccines and parasites control as needed for my pet. I give permission to have my pet's likeness and/or picture and medical story posted on social media. I assume responsibility for all charges 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. I understand that if I do not pay for services as agreed, I agree to pay all costs of collection.

Owner or Responsible Party

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Patient/Client Information Form

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