If you are human, leave this field blank. Name * First Last * Last Name * Spouse First Spouse Last * Last Email * Home Phone Cell Phone Work Phone Alternate Phone Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Employer License # or State ID List anyone else who is authorized to have your pets treated Do you give us permission to release your pet's records to a third part, such as a kennel or groomer if they call for them? Yes No About your pet(s) Name Breed Date of Birth Neutered? Sex Yes No Male Female Yes No Male Female Yes No Male Female Add Another Pet List any medical problems that the doctor should be aware of. Include any old injuries, chronic conditions and allergies. When were the last vaccines given and where? How did you hear about us? Payment is expected in full at the time of service - we do not bill should finances be a concern, please discuss this with a technician prior to exam. We do accept cash, Visa, MasterCard and Discover, sorry no American Express. Checks are accepted with the information provided above; however, we do not accept checks as payment of the first visit. *Before your first visit please review our policies.