testing Veterinary Office Financial Policy Full payment is required at the time of service unless arrangements are made with the Doctor or the Office Manager. Without a verifiable social security number, we will not be able to offer any type of payment arrangements. I understand that if payment arrangements are made, there will be a 1.5% monthly interest fee for this courtesy. By signing this form, you acknowledge your responsibility.Name Signature Appointment Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Social Security Drivers License Date MM slash DD slash YYYY Patent Registration FormOwner's Name Spouse Name Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneEmployer's Name Employer's Address Spouse's Employer's Name and Address Spouse's Employer's Phone No.Pet's Name Pet's Date of Birth (Age) MM slash DD slash YYYY Type of animal Dog Cat Other Other Sex Male Female Neutered Spayed Breed Color Reason for Visit Previous Veterinarian(s) where records could be obtained if necessaryList all chronic problems and types of medication and dosage your pet is takingHow did you first hear of us? Yellow Pages Drive By Saw Sign Live Nearby Direct Mail Other Individual we may thank Other Name Address Street Address VACCINES:Dog DHLPP (Parvo, Distemper) (Date) MM slash DD slash YYYY Rabies 1 or 3 Year (Date) MM slash DD slash YYYY Corona (Date) MM slash DD slash YYYY Bordetella (Date) MM slash DD slash YYYY Lyme Disease (Date) MM slash DD slash YYYY Is your dog on a heartworm Preventive? (Date) MM slash DD slash YYYY Feline FVRCP (Distemper) (Date) MM slash DD slash YYYY Rabies 1 or 3 Year (Date) MM slash DD slash YYYY Feleuk (Date) MM slash DD slash YYYY FIP (Date) MM slash DD slash YYYY How do you plan for your visit? Check cash Credit Card PLEASE COMPLETE BOTH SIDES OF FORM.
