24/7 Emergency Services
200 Commerce Street | Williston, VT 05495
Where should we send a copy of your pet’s records?
Referring animal hospital
Mailing Address P.O. Box / Street City/Town State Zip
Are you 18 years of age or older? Yes No
How did you hear about us? Web Veterinarian Friend Yellow Pages Other:
What form of payment will you be using? Cash Check Visa MasterCard Discover American Express Care Credit
Dog Cat Other:
Gender Male Female Unknown
Spayed / Neutered Yes No Unknown
Date of Birth / Age
Reason for Visit
I assume responsibility for the above described pet and hereby authorize the veterinarian to examine, prescribe for, and provide treatment as deemed necessary for the health, safety, or well-being of the above described pet. I assume responsibility for all charges incurred in the care of this animal regardless of outcome. I also understand that these charges will be paid at the time of release and that a deposit may be required prior to treatment. I will be responsible for any fees incurred by BEVS in the process of collecting my balance.
A 50% DEPOSIT MAY BE REQUIRED PRIOR TO TREATMENT WITH BALANCE DUE AT DISCHARGE
200 Commerce Street, Williston, VT 05495 | (802) 863-2387 | Fax (802) 863-2348 | email@example.com