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Pet Owner Information
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Would You Like to Add Information for a Spouse/Co-Owner?
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Employment:
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Name:
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Patient Information
Pet's Name
Breed
Color
Sex
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Male
Female
Age
Spayed/Neutered?
Select One
Yes
No
Allergic Reactions
Select One
Yes
No
List dates boosters were last given:
Is your pet currently on a special diet or medication?
Is your pet on Heartworm prevention(What Kind)?
Is your pet on Flea prevention(What Kind)?
Is your pet on Tick prevention(What Kind)?
What food does your pet eat?
List all previous problems that we should know about:
Additional Pets
Pet's Name
Breed
Color
Sex
Select One
Male
Female
Age
Spayed/Neutered?
Select One
Yes
No
Allergic Reactions
Select One
Yes
No
List dates boosters were last given:
Is your pet currently on a special diet or medication?
Is your pet on Heartworm prevention(What Kind)?
Is your pet on Flea prevention(What Kind)?
Is your pet on Tick prevention(What Kind)?
What food does your pet eat?
List all previous problems that we should know about:
Medical Consent/Financial Agreement
I voluntarily consent to medical care for my pet which may include emergency services, diagnostic procedures, and hospitalization. Such medical care may be provided by a veterinarian or veterinary technician.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of services, procedures, or treatments in the hospital. I agree to pay for services rendered to my pet, 75% of estimated fees will be due at admission and the balance is due at the time of discharge.
I also understand that an estimate is only an estimation of charges and the actual fees may vary slightly from the estimate given to me at the time of admission. When possible the staff will discuss additional charges ahead of time but I understand that emergency situations may arise that will entail additional fees. I accept that the clinic will not be held responsible for any damage or loss of belongings left with my pet; any belongings not picked up within 2 months of my pet’s stay will be discarded or donated at their discretion.
I further understand that patients must be discharged by 6:30am the following morning, or 6:30am Monday morning if admitted Saturday or Sunday, it is my responsibility to pick up or transfer my pet by that time. Charges will occur for late discharge ($30 for every 15 minutes late past closing) or my pet will be picked up by Animal Control if I fail to contact VES promptly regarding any delays.
Signature of Owner or Responsible Agent*
(Required)
First
Last
Email Consent
I agree to receive email communications.
I agree to receive marketing offers and updates via your preferred/primary email. You'll still receive services and account related emails if you do not check the box.
SMS Consent
I agree to receive SMS communications.
I agree to receive recurring automated messages about pet care, appointment reminders, marketing communications, and offers to the mobile number provided. Your consent is not required, and you may opt out at any time by replying STOP. Msg & data rates may apply. Message frequency may vary.
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