308.236.5912 / 800.689.5912
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So that we may become better acquainted, please complete the following:
Date:
Owner:
Spouse:
Email:
Address:
City:
State:
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Zipcode:
Home Phone:
Cell Phone:
Owners Work Number
May we contact you at work?
Reason for Visit
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Reason For Veterinary Appointment
Preferred Veterinary Visit Date
Preferred Veterinary Visit Time
Arrival Date
Departure Date
Pet Name:
Breed:
Sex:
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DOB:
Color and Unique Markings:
What does he/she eat?
How much?
When?
Name of medication and dosing instructions:
So that we are able to meet your needs, which do you feel most applies to you?
Is your pet on heartworm medication?
Do you brush your pets teeth?
I prefer to be present when my pet is examined and treated?
Things you want us to know about your pet.
Other Concerns?
Pet Name:
Breed:
Sex:
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DOB:
Color and Unique Markings:
What does he/she eat?
How much?
When?
Name of medication and dosing instructions:
So that we are able to meet your needs, which do you feel most applies to you?
Is your pet on heartworm medication?
Do you brush your pets teeth?
I prefer to be present when my pet is examined and treated?
Things you want us to know about your pet.
Other Concerns?
How did you first become aware of Hilltop Pet Clinic?
Owner specifically represents that he or she is the sole owner of the pet or the agent of the owner with the owner's permission to board or have veterinary services performed for the pet.
Owner agrees that prior arrangements must be made, and there will be an additional charge of $25 for pets admitted or discharged during other than regular office hours.
Owner understands that pets observed to have fleas or ticks or worms will be treated at the owner's expense.
Owner authorizes Hilltop Pet Clinic to transport to the pet as necessary to receive medical treatment or other services as requested by the owner.
If a pet becomes ill, or otherwise requires veterinary care, Hilltop Pet Clinic will attempt to notify the owner immediately, if owner is not available, we will begin necessary medications or give other requisite attention to the pet, and the expense thereof shall be paid by the pet's owner.
Any pet left for 10 days beyond the agreed date of pickup may be disposed of at the discretion of Hilltop Pet Clinic. Any cost incurred it the responsibility of the pet's owner.
Preferred method of payment:
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