|Home Phone Number (required)
|Cell-Phone Number (required)
|Other Contact Numbers
|E-Mail Address (required) :
|Birth Date (required)
|Spouse/Co-Owner Work Phone
|We will gladly prepare a written estimate if you desire (please ask any staff member). This will be important to you since all fees are due at the time services are rendered.
|In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we take Visa, Mastercard, Discover, American Express, Care Credit, and Reliant. There will be a $35.00 service charge on all returned checks.
|To prevent the spread of infectious diseases, hospitalized and boarded patients must be current on all vaccines as required by hospital policy. Those patients must also be free from external and internal parasites.
|The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice. The person signing below will be responsible for all charges incurred in the care of this pet(s).
|Signature of Responsible Agent for pet(s) (required)
(I agree that my electronic signature is the legal equivalent of my manual signature)
|How/Why did you select us?
ESSENTIAL PET INFORMATION
|Type of Pet (required)
|Pet's Name (required)
|Date of last vaccinations
|Please list any additional pets here (include species, pet name, gender, D.O.B, color, if spayed/neutered, and date of last vaccinations)