Owner's Name *

First Name

Last Name

Primary Owner's DOB: *

Note: If you are under 18 years of age, you will need to call the clinic directly prior to submitting this form/paperwork.

MM

DD

YYYY

Co-Owner's Name

First Name

Last Name

Phone *

(###)

###

####

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pet Name *

First Name

Last Name

Is your pet spayed or neutered? *

Please pick one

Spayed

Neutered

N/A

Your Pet's Birthdate *

MM

DD

YYYY

Cancellation/No Show/Late Policy *

By completing this form, you agree/understand our Cancellation/No Show/Late Policy terms & conditions: -24 hours' notice is required for all appointment cancellations. -Less than 24 hours advance notice for all Medical Examinations = $50.00 cancellation fee. -Less than 24 hours advance notice for all scheduled Surgeries = $75.00 cancellation fee. -This fee will be automatically charged to your credit card on file. -If we currently do not have a credit card on file, we will either mail you an invoice for payment or your account will show a balance due upon your next visit with us and will be added to your total due. -Anyone who either forgets or consciously chooses to forgo the appointment for whatever reason will be considered a “no-show.” You will be charged for your “missed” appointment. -If you arrive late, your appointment may be shortened in order to accommodate others whose appointments follow yours. -Depending upon how late you arrive, our medical team will then determine if there is enough time remaining to start a medical examination/surgery. We may need to reschedule your appointment for another time to safely complete your appointment. -Regardless of the length of the treatment actually given, you will be responsible for the “full” session AND may be subject to a late fee.

I have read (understand/agree) to the Cancellation/No Show/Late Policies