Client Name *

First

Last

Additional Authorized User/Phone #:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone

Email *

Would you like reminders sent to you via e-mail? *

Yes
No

Pet Information

Pet Name *

Breed *

Age *

Gender *

Color *

Has your pet been spayed/neutered? *

Yes
No

Known Allergies:

How did you hear about us?

(client referrals receive $15 credit to account)

Is your pet on heartworm preventative?

Yes
No

If yes, which brand?

Is your pet on flea & tick preventative?

Yes
No

If yes, which brand?

Vaccinations

I hereby authorize the veterinarian to examine, treat and prescribe for the above described pet. I assume responsibility for all charges incurred in the care of the pet. I also understand that all professional fees are due at the time service is rendered. In the event that an invoice is not paid in full and is sent to collections, a 40% price adjustment will be added to the total due to collection fees. On occasion, my or my pet’s likeness may be captured on video or other media. I hereby authorize Foothills Animal Clinic and Heartland Veterinary Partners to use, broadcast, and/or reproduce my and my pet’s likeness in video, print, or other media. I understand I will not be compensated for any such use.

I authorize

Signature of client responsible for pet(s) *

Clear Signature

Date

Low Cost Vaccine Clinic Form

Low Cost Vaccine Clinic Form

Pet Information

Make An Appointment

Have a question?

Location

Contact Information

Hours