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.NameSignatureAppointment Date Time : HH MM AM PM Social SecurityDrivers LicenseDate Patent Registration FormOwner's NameSpouse NameAddress Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneEmployer's NameEmployer's AddressSpouse's Employer's Name and AddressSpouse's Employer's Phone No.Pet's NamePet's Date of Birth (Age) Type of animal Dog Cat Other OtherSexMaleFemaleNeuteredSpayedBreedColorReason for VisitPrevious 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 OtherNameAddress Street Address VACCINES:Dog DHLPP (Parvo, Distemper) (Date) Rabies 1 or 3 Year (Date) Corona (Date) Bordetella (Date) Lyme Disease (Date) Is your dog on a heartworm Preventive? (Date) Feline FVRCP (Distemper) (Date) Rabies 1 or 3 Year (Date) Feleuk (Date) FIP (Date) How do you plan for your visit? Check cash Credit Card PLEASE COMPLETE BOTH SIDES OF FORM.
