Owner *

First Name

Last Name

Spouse/Other Owner *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone (Primary Contact) *

Country

(###)

###

####

Cell Phone (Primary Contact) *

Country

(###)

###

####

Secondary Contact

(###)

###

####

Date of Birth *

MM

DD

YYYY

Pet's Name *

First Name

Last Name

Please Mark ANY Symptoms You Have Noticed With Your Pet *

Straining

Loss of Balance

Vomiting

Breathing Problems

Scooting

Weakness

Coughing

Scratching

Weight Problem

Diarrhea

Seems Depressed

Seizures

Eye Bulging/Bloodshot

Shaking Head

Stays Inside Only

Gagging

Sneezing

Other

AUTHORIZATION *

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for all charges in the care of this animal. I understand that these charges must be paid at the time of release & that a deposit may be required. We will make every attempt to perform the services you have requested for your pet without sedation. Should sedation be necessary for the health of your pet and/or the safety of our staff, do we have permission to sedate?

Yes, please sedate to ensure the safety of my pet and the staff.

No, I understand my pet will not have his/her services performed if he/she becomes unmanageable.

Date *

MM

DD

YYYY

Method of Payment *

Cash

Card

Check

Care Credit