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: _________________________________________
-----------------------
Office Use Only
CHART NO.
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