BARKSDALE AIR FORCE BASE



BARKSDALE AIR FORCE BASE

Veterinary Services/ VTF

The staff would like to thank each of you for your service to our country. Your sacrifices and dedication are part of what makes this country great and we truly appreciate you!

Please help us serve you better by updating your information so that we can keep our files up to date.

Date: _____________

SPONSOR’S INFORMATION (should match Military ID card):

Sponsor’s Last Name: _______________________ Sponsor’s First Name: __________________ MI: ___

Last 4 SSN: _______ Current Rank/Pay Rate: ____________Branch of Service: _______Retired? Yes/No

Do you reside on Base? ________ Home Address: ______________________________________________

City: _____________________ State: _________ Zip: __________ Home Phone: ____________________

Duty Organization: ______________________ Work/Duty Number: _____________________________

Email: ____________________________________________________________________________________

Spouse (or) Emergency Contact NAME/Ph. # (if any):__________________________________________

| |PET # 1 |PET # 2 |PET # 3 |

|NAME | | | |

|SPECIES / BREED | | | |

|DATE OF BIRTH or | | | |

|AGE | | | |

|COLOR | | | |

|M or F | | | |

|SPAYED/ | | | |

|NEUTERED? | | | |

|MICROCHIP NUMBER | | | |

Any vaccination or drug reactions or allergies? ______ If yes, please explain (include name of drug / vaccination, the reaction and any treatment given)

Do you authorize clinic staff to provide confirmation of vaccine & medical records to your grooming/boarding facility? YES NO

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