WELCOME TO GOVERNOR ANIMAL CLINIC

Thank you for giving us the opportunity to care for your pet. Please print in all spaces, and fill out form completely. All information will be confidential.

Date                                                 

Your Name                                                                               Spouse/Partner                                                          

Address                                                                    

City                                       State                    Zip               

Home Phone                                             

Cell Phone                                              

Employer                                                                 

Work Phone                                                            

Occupation                                                              

Emergency Phone                                                  

Spouse/Partner                                                          

Employer                                                                  

Phone                                                                    

Drivers Licence#                                                      

E-mail Address                                                                     

Please give 24 hours notice if appointments cannot be kept

We will gladly prepare a written estimate if you desire. This will be important to you since all professional fees are due at the time services are rendered.   Although we do not offer billing services, we take Master Card, VISA, Discover and American Express. Please ask us about our Veterinary Credit Card (Care Credit) if you wish to arrange financing.

There will be a $25.00 service charge for any check returned unpaid.

PLEASE NOTE:    Hospital personnel are not here 24 hours a day. Veterinary services are provided during nighttime hours as deemed necessary by the veterinarian in charge.

ALSO: Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs and collection charges involved as a result of any collection activity.

Signature of responsible agent for pet(s)

Date                                   

 How did you first hear about us? (please be specific)                                                                                   

   ESSENTIAL PET INFORMATION

PLEASE LIST ALL PETS AT HOME and include this information for each one;

Pet's Name          Cat/Dog     DOB   Sex /Altered       Breed/color

Have any of the pets listed above ever shown any signs of aggression ? yes       no      towards; people             other animals             ?

comments;