PEDLEY VETRINARY HOSPITAL



PEDLEY VETERINARY HOSPITAL

6363 Pedley Rd.

Riverside, CA 92509

(951) 685-5224

Date: ____________________

Your Name: ____________________________________________________ ________________________

LAST (as on Drivers, License) FIRST SPOUSE

Street Address ____________________________________________________ Home ( ) ______________

City ________________________________________________Zip__________ Cell ( ) ______________

Employer_________________________________________________________ Phone ( ) ______________

Employer (spouse) _________________________________________________ Phone ( ) ______________

Emergency Contact: Name __________________________________________ Phone ( ) ______________

Email Address: ____________________________________________________

| | |Yellow Pages |Phonebook for | | |

| Of payment |

ALL MAJOR CREDIT CARDS ACCEPTED

Driver’s License No. ______________________________________________ Your Date of Birth ________________________________________

(Used for cross reference purposes/check guarantee)

|PET| | | |PET |

|HIS|Pet’s Name __________________________ |Pet’s Name __________________________ |Pet’s Name __________________________ |HIST|

|TOR|Dog or Cat |Dog or Cat |Dog or Cat |ORY |

|Y |Breed ______________________________ |Breed ______________________________ |Breed ______________________________ | |

| |Male or Female Neutered: Y or N |Male or Female Neutered: Y or N |Male or Female Neutered: Y or N | |

| |Color _______________________________ |Color _______________________________ |Color _______________________________ | |

| | | | | |

| |Pet’s Date of Birth ____________________ |Pet’s Date of Birth ____________________ |Pet’s Date of Birth ____________________ | |

| | | | | |

| |( Dates of Last Vaccines………...… |( Dates of Last Vaccines………...… |( Dates of Last Vaccines………...… | |

| |Dogs: Distemper/Parvo________________ |Dogs: Distemper/Parvo________________ |Dogs: Distemper/Parvo________________ | |

| |Bordetella_____________________ |Bordetella_____________________ |Bordetella_____________________ | |

| |Corona _______________________ |Corona _______________________ |Corona _______________________ | |

| |Lyme _________________________ |Lyme _________________________ |Lyme _________________________ | |

| |Rabies ________________________ |Rabies ________________________ |Rabies ________________________ | |

| |Cats: Distemper/Flu __________________ |Cats: Distemper/Flu __________________ |Cats: Distemper/Flu __________________ | |

| |Leukemia______________________ |Leukemia______________________ |Leukemia______________________ | |

| |FIP __________________________ |FIP __________________________ |FIP __________________________ | |

| |Rabies ________________________ |Rabies ________________________ |Rabies ________________________ | |

| |A |B |C | |

PLEASE READ AND SIGN

There will be an 18% (APR) surcharge on all unpaid balances per billing cycle if not paid in 30 days. I understand that there will be a $25.00 charge for all returned checks. If my account becomes delinquent and if referred to an attorney or collection agency for collections, I understand that I may have to pay up to 35% attorney or collection fees.

Signature: _______________________________________________________________ Date: _________________________________________

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Office Use Only

CHART NO.

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