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Owner's Name

Today's Date

Address

City

State

Zip

Cell Phone

Home Phone

Work Phone

May we phone you at work?

Email

Preferred Method of Contact

Spouse/Co-Owner/Other Name

Spouse/Co-Owner/Other Phone Number

Emergency Contact Name:

Emergency Contact Phone:

Relationship to Emergency Contact:

How Did You Hear About Us?

Who may we thank for the referral?

Please specify:

Pet Information

Pet Information

Pet's Name

Age or Date of Birth

Species

Please specify:

Sex

Breed

Color

Current medical problems?

Current medications?

Previous Veterinarian(s) for past records

Would you like to be present during your pet’s exam/treatments?

Statement

Terms of Service

By completing this form, I authorize the release of my pet's veterinary information (patient medical records) to Animal Medical Center of the Village representatives.

I, the undersigned, certify that I am the owner or authorized agent for the owner of above listed pet(s), and accept full financial responsibility. I accept that full payment for services and products is expected at the time my pet is discharged, and I agree to pay all charges associated with these treatments according to the policies set forth by the practice.

Acceptance

I acknowledge and agree to the terms and conditions of service