Passion Fur Paws-New client form

Owner Information

OWNER'S NAME

CO-OWNER'S NAME

ADDRESS

HOME PHONE

OWNER'S CELL

CO-OWNERS CELL

EMAIL ADDRESS

EMERGENCY CONTACT NAME

EMERGENCY CONTACT NUMBER

HAVE YOU HAD PETS HERE IN THE PAST?

Yes

No

Pet Information

PET NAME

SPECIES*

Dog

Cat

BREED OF PET*

AGE OF PET*

COLOR*

SEX*

Male

Female

NEUTERED/SPAYED

Yes

No

DO YOU HAVE PET INSURANCE?

Yes

No

WHO MAY WE THANK FOR REFERRING YOU?

INFORMED CONSENT

INFORMED CONSENT I am financially responsible for the patient described above and agree to pay all fees incurred for the care of such patient. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee the successful outcome of any such procedure.

I understand the total payment is due at the time service is rendered.

PLEASE SIGN*

DATE*