Client Information

Pet Owners Full Name:
Spouse/Partner:
Address:
City State & Zip
Home Phone:
Work:
Cell:
Spouse/Partner Work Phone:
E-mail:
Preferred Payment Methods:

How did your hear about us?
(Check all that Apply)

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Other

Patient Information
Pets Name:
Other:
Breed   Color:
D.O.B.   Sex:
Spay/Neutered:
Date of your pets last rabies vaccination?
Any current medications?
Any known medical conditions/allergies?
Who is your regular veterinarian?
At which hospital?
Why are you bringing your pet in today?
   
 

Payment in full is required at the time services are rendered on non-hospitalized patients. If your pet needs to be hospitalized, an estimate for cost of services will be provided, and 50% of the upper end of the estimate will be required as deposit at that time. Further deposits may be required during the course of hospitalization.
All fees must be paid in full when your pet leaves the hospital


I am the owner / authorized agent for the owner of the animal being presented. I authorize the Center for Animal Referral and Emergency Services to examine and render immediate life saving treatment if necessary. I understand that no guarantee is made regarding the outcome of any diagnostics or treatment performed. I understand that I have the right to decline any of the diagnostics or treatment recommended by the attending veterinarian. I understand that I am making an informed financial decision on payment, that I agree to pay all fees associated with collection of the debt.

Owner/Agent Signature: _____________________ Date: ___________________

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