Owner Information
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| Owner's First Name: |
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| Address: |
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State: |
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Zip: |
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| Home Telephone: |
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| Cell Phone: |
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| Work Phone: |
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| E-mail Address: |
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| SSN: |
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| State ID#: |
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| Employer: |
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State: |
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Zip: |
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| How Did You Hear About Us? |
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Pet Information
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| Pet's Name: |
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| Date of Birth: |
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| Sex: |
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| Spayed/Neutered: |
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| Species: |
If Other: |
| Breed: |
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| Color(s): |
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| Date of Last Vet Check-up: |
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Last Rabies Vaccine: |
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| Name of Your Primary Veterinarian/Hospital: |
Payment Terms:
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| Payment is required when services are rendered. We accept Cash, Visa, MasterCard, American Express, Discover, Debit – ATM Cards and Care Credit. A deposit of the entire low end of our estimate is required on all patient admissions, and the balance is due upon patient discharge. |
Patient Agreement:
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| I give permission to the Veterinary Emergency and Referral Group to perform diagnostic, surgical and medical treatment as deemed advisable. It is understood that such procedures of diagnosis, surgery, and medical treatment will be discussed with me before proceeding except in emergency situations. In many cases, it is impossible to determine in advance the extent of surgical and/or medical treatment required, and I understand that the actual cost may be lower or higher than the estimate presented to me. I agree to make prompt and complete payment upon discharge of the above animal. I also understand that if I neglect to pick up the above animal, the animal will be considered abandoned. In doing so, I understand that this does not relieve me from my financial obligation. I further understand that in case of non-payment, I will be subject to all billing toward further care and finance/collection charges associated with my account. |
| Date: (M/D/Y)
By clicking the "Send Information" button you agree to the conditions stated above.
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