Welcome to Castle Peak Veterinary Service Please print and fill in the following information regarding you and your pet(s) Owner's information: Name:______________________________________________ Mailing Address:_______________________________________________________ E-mail Address:_______________________________________________________ Home Phone #: ( )_____-_______ Cell Phone #:( )_____-________ Work #:( )_____-_______ Social Security #:______-_____-______ Employer:________________________________________________________________________
Referred To Castle Peak Veterinary By: Friend:________________________ Newspaper:___________________________ Yellow Pages:____________________ Other:____________________________
Pet's Information: Name:_____________________ Dog:____ Cat:____ Breed:__________________________ Birth Date:____-____-____ Male: ___ Male Neutered:___ Female:___ Female Spayed:___ Color/Markings:__________________________________________________ Vaccination History: Rabies Given:___/___/___ Distemper Given:___/___/___ Bordatella Given___/___/___ Feline Leukemia Given___/___/___ Feline Distemper Given:___/___/___ Name of clinic where vaccinations were given:___________________________________________
2nd Pet's Information: Name:_____________________ Dog:____ Cat:____ Breed:__________________________ Birth Date:____-____-____ Male: ___ Male Neutered:___ Female:___ Female Spayed:___ Color/Markings:__________________________________________________ Vaccination History: Rabies Given:___/___/___ Distemper Given:___/___/___ Bordatella Given___/___/___ Feline Leukemia Given___/___/___ Feline Distemper Given:___/___/___ Name of clinic where vaccinations were given:___________________________________________
I authorize treatment of the above names pet(s) and agree to pay all charges as rendered for such treatment. I acknowledge and understand that I am responsible for all of the services provided to my pet(s) I hereby agree to pay my account as services are provided. Payment is expected when services are rendered, unless prior approval from a doctor is authorized. If for any reason a payment plan is established for an emergency situation, I agree to pay promptly as agreed in writing. I also understand that there will be a $2.00 service charge and a 2% billing fee for accounts extended beyond 30 days. If illigation becomes necessary I will be held liable for any attourney fees court cost that are applicable.
__________________________________________________________________________________/___/___ Owners' Signature Date
For future purposes: When sending out reminders for vaccinations, would you like to be contacted by E-mail______ or U.S.Mail ______?