Green Valley Animal Hospital



WelcomeThank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you may have about your pet’s health. To ensure the best care possible, please take the time to fill out this form. Thank You!RegistrationName of Owner:_____________________________________________ SSN/DL#_______________________Mailing Address:____________________________________________________________________________City:____________________________ State:______________ Zip Code:__________________Spouse:________________________________________ SSN/DL#_______________________Home Phone:____________________________________Work Phone:___________________________________ Spouse Work:_____________________________Cell Phone:______________________________________ Spouse Cell:_____________________________E-Mail Address:_________________________________________________________________Would you like E-Mail reminders? ___Yes ___NoEmergency Contact Name:___________________________ Phone:______________________ 4286253371850How did you learn about our clinic?___Recommended, by whom?______________________________________________________Yellow Pages ___Sign ___Recommendation ___Internet/Facebook ___Other**If Other please explain_________________________________________________________020000How did you learn about our clinic?___Recommended, by whom?______________________________________________________Yellow Pages ___Sign ___Recommendation ___Internet/Facebook ___Other**If Other please explain_________________________________________________________Pet Health HistoryName of Pet:_________________________________ Dog Cat Other:__________________________Breed:___________________________ Color:_______________ Birth Date:_____________________Gender: Male Male Neutered Female Female SpayedMajor Surgeries or Medical Illnesses:______________________________________________________________________________________________________________________________________________________________________Current Medications (including vitamins/supplements):_______________________________________________________________________________________________________________________________________________________Current Diet (Including Treats):___________________________________________________________________________________________________________________________________________________________________________Pet Health HistoryName of Pet:_________________________________ Dog Cat Other:__________________________Breed:___________________________ Color:_______________ Birth Date:_____________________Gender: Male Male Neutered Female Female SpayedMajor Surgeries or Medical Illnesses:______________________________________________________________________________________________________________________________________________________________________Current Medications (including vitamins/supplements):_______________________________________________________________________________________________________________________________________________________Current Diet (Including Treats):___________________________________________________________________________________________________________________________________________________________________________Pet Health HistoryName of Pet:_________________________________ Dog Cat Other:__________________________Breed:___________________________ Color:_______________ Birth Date:_____________________Gender: Male Male Neutered Female Female SpayedMajor Surgeries or Medical Illnesses:______________________________________________________________________________________________________________________________________________________________________Current Medications (including vitamins/supplements):_______________________________________________________________________________________________________________________________________________________Current Diet (Including Treats):___________________________________________________________________________________________________________________________________________________________________________Pet Health HistoryName of Pet:_________________________________ Dog Cat Other:__________________________Breed:___________________________ Color:_______________ Birth Date:_____________________Gender: Male Male Neutered Female Female SpayedMajor Surgeries or Medical Illnesses:______________________________________________________________________________________________________________________________________________________________________Current Medications (including vitamins/supplements):_______________________________________________________________________________________________________________________________________________________Current Diet (Including Treats):___________________________________________________________________________________________________________________________________________________________________________Our payment policy requires payment in full at the end of your appointment.Payment options include: *Cash* Check*Visa*Mastercard*Discover *Care Credit*VetBillingCare Credit is available for fees exceeding $250 when a client has or opens a Care Credit account. Client understands the terms of Care Credit.VetBilling is a financing option that Green Valley extends to clients under extreme circumstances. Any financing via VetBilling must be approved by the manager prior to use.If checks are returned to Green Valley for Not-Sufficient Funds (NSF), the client will incur a charge of $35 to their account. Payment with cash or credit card is required to settle the account. If you have an outstanding bill, we cannot provide additional services until the past-due balance is paid in full.AuthorizationI hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. Signature of Owner:___________________________________ Date:____________________________ ................
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