Welcome Large 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 #Animal InformationType of SpeciesHerd SizeID/NumberBreedProduction ClassAnimal Location same as aboveYesNoIf noBilling InformationName of Credit Card Holder as listed on CardCheck oneVisaMCAmExDiscoverCareCreditCredit Card NumberSecurity CodeExp DateCredit Card Billing Address (if different from Prospective Buyers) 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 Signature giving authorization to charge card once exam is completeDate Date Format: MM slash DD slash YYYY Authorization 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 Additional AnimalsType of SpeciesHerd SizeID/NumberProduction ClassAnimal Location same as aboveIf noReason/Goal for Appt/herd check