Name of PetType of PetBreed of PetColorDate of BirthSexPet's Current MedicationsPet's Current DietPet's Current LifestylePlease check any symptoms or problems you have noticed about your pet Behavior Problems Bleeding gums Breathing Problems Diarrhea Eye Bulging or Bloodshot Gagging Lack of Appetite Limping Loss of Balance Scooting Scratching Seems Depressed Shaking Head Sneezing Thirst and/or Urination Increase Vomiting Weakness Other If other, please specifiyAuthorizationI hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all the 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 surgical treatment. I agree by signature below failure to pay at time of service will cause late chargers of 18% of balance to be assessed if not paid in full within 30 days. Balances that go over 30 days are subject to legal and collection proceedings. Necessary costs such as court fees, legal fees or any other fees incurred by D.C.A.H in the collection of this account will be client’s responsibility in fullSignatureDate MM slash DD slash YYYY Payment Method Cash Check Mastercard Visa Other If other, please specifiy Δ
