South 31 Veterinary Clinic
South 31 Veterinary Clinic
5911 U.S. 31 South
Indianapolis, IN 46227
317-788-0893
| |
|Client Information |
|Owner’s Name__________________________________ Spouse________________________ |
|Address______________________________________________________________________ |
|City ___________________________________________Zip Code____________________ |
|Phone Number: Home _________________________Work ___________________________ |
|Email Address_________________________________________________________________ |
|Place of Employment____________________________________________________________ |
|Employment Address____________________________________________Zip Code________ |
|Driver’s License Number ______________________________ |
| |
|Pet Information |
|Cat ο Dog ο Breed _______________ Male ο Female ο Spayed/Neutered ο |
|Date of Birth or Age ___________________ Pet’s Name ____________________ |
|Reason for visit today ___________________________________________________________ |
|Date of last vaccination _______________________ |
|Known allergies ________________________________________________________________ |
|Clerical Information |
|How did you learn about our hospital? |
|ο Personal recommendation Whom may we thank? ________________________ |
|ο Hospital sign ο Yellow pages ο Advertisement ο Other ____________ |
|We will gladly prepare an estimate for any services. Please don’t hesitate to ask the receptionist or doctor. |
|PROFESSIONAL FEES ARE DUE WHEN SERVICES ARE RENDERED. |
|*To prevent the spread of infection diseases and parasites, all pets must be vaccinated and be free of internal and external parasites or they will be |
|treated upon entry or discovery at the owner/agents expense. |
|*Authorization for emergency care: Should an emergency arise, I authorize the medical staff to administer a tranquilizer or perform such emergency |
|procedures as may be necessary for the health of my pet. I agree to pay, in full, for all necessary services rendered for and to my pet. |
|*I agree and understand that I am responsible in full for all fees charged, as well as any and all fees that South 31 Veterinary Clinic might incur in an |
|effort to collect such fees. This includes any and all collection fees, attorney fees and/or court fees. |
|ALL SERVICES MUST BE PAID AT THE TIME OF DISCHARGE. |
|PAYMENT WILL BE MADE BY: CASH, CHECK OR CHARGE CARD |
|I HAVE READ ALL OF THE ABOVE AND UNDERSTAND THE OFFICE POLICIES OUTLINED ABOVE: |
|Owner/Agent _______________________________________Date_______________ |
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