Payment is due when services are rendered. A deposit will ...

[Pages:1]4585 Weston Road, Weston, FL 33331 Phone: (954) 389-5656 Fax: (954) 954-385-8655

Email: westonroadanimalh@ Website:

Payment is due when services are rendered. A deposit will be required for all in hospital treatments or services.

OWNER INFORMATION

Owner Name______________________________ Spouse Name________________________________

Address__________________________________ Apt #______ City/Zip___________________________

Phone# (Home)____________________________Spouse Cell #_________________________________

Work # __________________________________Occupation: __________________________________

E-Mail Address_______________________________________Fax#______________________________

Please circle where you first heard about us: Friend (who?) _____________________________________

Drive By Yellow Pages Internet

Other: ________________________________________

Is your pet Microchipped? Yes/ No

PATIENT INFORMATION

Pet's Name_______________________________Breed____________________Color_______________

Sex: Male/Intact Female/Intact Male/Neutered Female/Spayed Birthdate______________

Regular Diet (Brand Name) ____________________________Can/Dry? Treats____________________

Current Medical Problems: ______________________________________________________________

Current Medications & Preventions________________________________________________________

Does your pet have any allergies or reactions to vaccines or medications? ________________________

List any previous surgeries or serious illness: ________________________________________________

Does your pet live inside, outside or both? __________________________________________________

What other type of pets live in your household? _____________________________________________

Previous Veterinarian/Phone number ______________________________________________________

ARE YOU OVER 18 YEARS OF AGE? YES / NO

I understand that I am responsible for payment of all charges incurred for the treatment of my pet and all fees including but not limited to bank charges, collection agency, attorney and/or court costs should my account become delinquent. I understand that this hospital only accepts CASH or CREDIT CARD for payment. I understand and agree to the above payment policy as long as my pet is treated at Weston Road Animal Hospital

Client Signature___________________________________ Date_____________________

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