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East Side Veterinary Clinic
Owner’s Date of Birth____________________________
Home Phone ( _) Cell (_____) _______________
Work Phone (_____)_______________________
I would like reminders sent by: ( _____) postcard (_____) email
Cell (____)_____________________Work phone (____)_____________________
Name___________________________( ) Dog ( ) Cat
( ) Male ( ) Female ( ) Spayed ( ) Neutered
PLEASE FILL OUT OTHER SIDE OF THIS FORM
How did you find us?
( ) Client referral. May we have their name so we can thank them?
( ) Directory ( )Website ( )Advertisement
East Side Veterinary Clinic ( ) MAY ( ) MAY NOT use my pet’s photo on social media networks.
I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
Method of Payment (please check all that apply):
( ) Cash ( ) Visa ( ) MasterCard ( ) Discover
( ) AmEx ( ) Check; S.S.N. or current Driver’s License required
To prevent the spread of infectious diseases and parasites, hospitalized animals must be current on all vaccines and free from external and internal parasites.
New clients receive 10% OFF first exam. ( please visit special offers page for more details)