CONTACT PREFERENCES:

Phone Type Cell Home Work

Primary Email

Text (cell number)

(service provider)

Would you like to receive our Monthly Email Newsletter?

 Yes 

 No

Would you like to receive text messages for pet updates?

 Yes 

 No

Would you like to receive Email vaccination reminders?

 Yes 

 No

FINANCIAL RESPONSIBILITIES:

All fees are due at the time services are rendered. Payment in full is expected at the time of Check Out. In the event that your pet is hospitalized with on-going treatment you will be presented with an estimate for cost of treatment and a deposit will be required at that time. You will be advised daily of your account balance. Accounts with outstanding balances are subject to a monthly $3 billing fee and a monthly finance charge of $3.00 or 1.5% of the outstanding balance whichever is greater.

Signature:

 

(Signature will be requested at the time of check-in)

GENERAL PATIENT INFORMATION

You have the right to consent to or refuse any proposed surgery or medical procedure at any time prior to its performance. Bishop Ranch Veterinary Center & Urgent Care maintains personnel and facilities to assist your pet′s veterinarian in the performance of various surgical and therapeutic procedures. These procedures may involve unsuccessful results, complications, injury or even death from both known and unforeseen causes, and no warranty or guarantee is made as to results or cure.

Permission granted for release of records:   Yes   No

	Pet #1	Pet #2	Pet #3
Name of Pet
Gender:
Date of Birth / Age of Animal:
Type of Animal: (dog,cat,bird,exotic)
Breed:
Spayed/Neutered	Yes      No	Yes      No	Yes      No

Additional Notes or comments: