Welcome Dog/Cat/Small Animal Name*Driver License #*SpouseAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail Farm Premise ID #Patient Information:Name of PetType of SpeciesSpayed/NeuterYesNoBreedAgeSexColorVaccination History: (Check all pet has received) Dog - DHLPP(Distemper,Parvo,Lepto) Dog Heartworm Test Dog - Rabies Dog - Bordatella Cat- FVRCP(Respiratory Diesase) Cat - Felv Cat - Rabies Cat - FELV/FIV testPrior Surgery?If Yes, What ProcedureOther Vaccinations/HistoryMedications/SupplmentsDescribe you patient's dietPlease Check any current symptoms that you have noticed with your pet: Behavior change Lack of Appetite Depressed/Lethargic Weakness Sneezing Coughing Limping Bleeding Gums Trouble Breathing Diarrhea Vomiting Scooting Scratching Increased Thirst/Urinations Loss of balance/coordination Gagging Eyes Bulding or bloodshot Shaking HeadAuthorization and PaymentI hereby authorize the veterinarian to examine, prescribe for, or treat the above described animal. I assume responsibility for all charges incurred in the care of this/these animals. ALL PROFESSIONAL FEES ARE DUE AT THE TIME THAT SERVICES ARE RENEDERED. We will gladyly prepard a written estimate if you desire. (Please ask our Dr. or Staff) I also understand that these charges will need to be paid in full at the time services. In case of extensive medical or surgical procedures where full payment may be difficult at discharge, our office accecpts Visa, Mastercard, American Express, and Care Credit. There will be a service charge for any check returned unpaid. Also any unpaid balance can result in a monthly service charge.SignatureDate Date Format: MM slash DD slash YYYY