Client Registration

CLIENT INFORMATION

Where should we send a copy of your pet’s records?

Referring veterinarian

Referring animal hospital

Pet Owner

Co-Owner/Agent

Mailing Address
P.O. Box / Street

City/Town

State

Zip

Home Phone

Cell Phone

Work Phone

E-mail Address

Employer Name/Address

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

PET INFORMATION

Name

 Dog Cat Other:

Breed

Color

Gender
 Male Female Unknown

Spayed / Neutered
 Yes No Unknown

Date of Birth / Age

Current Medications

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