Text and Email Consent Form Please complete this form as accurately as possible. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Primary Phone *Secondary PhoneAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWho else is authorized to make decisions about your pet's healthcare? *FirstLastPhoneHow did you find out about our hospital? If you were referred by someone, who should we thank? *Pet's Name *Species (dog, cat, etc.) *Breed *Age/Date of Birth *Sex *MaleNeutered MaleFemaleSpayed FemaleDoes your pet have a microchip identification? *YesNoWhat is the microchip number?Do you have a second pet? *YesNoPet's Name *Species (dog, cat, etc.) *Breed *Age/Date of Birth *Sex *MaleNeutered MaleFemaleSpayed FemaleDoes your pet have a microchip identification? *YesNoWhat is the microchip number?Do you have a third pet? *YesNoPet's Name *Species (dog, cat, etc.) *Breed *Age/Date of Birth *Sex *MaleNeutered MaleFemaleSpayed FemaleDoes your pet have a microchip identification? *YesNoWhat is the microchip number?Do you have a fourth pet? *YesNoPet's Name *Species (dog, cat, etc.) *Breed *Age/Date of Birth *Sex *MaleNeutered MaleFemaleSpayed FemaleDoes your pet have a microchip identification? *YesNoWhat is the microchip number?Do you have a fifth pet? *YesNoPet's Name *Species (dog, cat, etc.) *Breed *Age/Date of Birth *Sex *MaleNeutered MaleFemaleSpayed FemaleDoes your pet have a microchip identification? *YesNoWhat is the microchip number?Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your pet. We accept credit cards (Visa, Mastercard, Discover, American Express), cash, check, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *I have read and accept the financial policy.CommentSubmit
