Owner: (required)
|
Phone: (required)
|
Co-Owner:
|
Co-Owner Phone:
|
|
Employer: (required)
|
Work Phone: (required)
|
Co-Owner Employer:
|
Co-owner Work Phone:
|
Other contact numbers:
|
Email Address: (required)
|
Pet Information |
Pet Name: (required)
|
Pet Date of Birth: (required)
|
Breed: (required)
|
Color/Markings: (required)
|
Species: (required)
Canine
Feline
Other
|
Is your pet spayed? (required)
Yes
No
|
Previous Veterinarian:
|
May we request records if needed?
Yes
No
|
Last Vaccinations:
|
DOG'S DHPP/Rabies/Bordetella:
|
CAT'S FVRCP/Rabies/FELV
|
Does your pet have any known illnesses, allergies or drug sensitivities? (required)
Yes
No
|
If yes, please list:
|
Has your pet ever had any seizures? (required)
Yes
No
|
Is your pet currently receiving any medications? (required)
Yes
No
|
If yes, please list:
|
If new client, how did you find us? (required)
Phone book
Sign
Referral
|
If referral, by whom?
|
Unless prior arrangements have been made, payment is due at the time of services. |
How the account is to be paid:
Cash
Check
Credit Card
|
Authorization and Consent: |
(required)
I am the owner of the above named animal or am responsible for the patient and have authorization to execute this consent.
I hereby authorize treatment of this animal and performance of such surgical or therapeutic procedures as you determine to be indicated and the use of anesthetics as you deem advisable.
It is agreed that past due accounts are subject to $5/month service charge and/or 1.5% monthly interest in addition to all costs of collection, including reasonable filing and attorney fees.
I am responsible for maintaining current addresses and phone contact information with Twin Cities Veterinary Clinic.
Any animal will be considered abandoned if within 10 days of written notice to remove the animal(s) mailed to the address above, the animal is not removed, and that upon such abandonment, Twin Cities Veterinary Clinic may destroy, sell or otherwise dispose of the animal without prejudice to its claim for fees or services needed.
|
Signature (please type your first and last name): (required)
|
Date: (required)
|
Processing ....