CLIENT INFORMATION

Primary Veterinarian:

Primary Animal Hospital:

Pet Owner:

Co-Owner:

Mailing Address:

P.O. Box / Street

City/Town

State

Zip

Pet Owner Primary Phone:

Primary Owner E-mail:

Co-Owner Primary Phone:

Co-Owner E-mail:

Are you 18 years of age or older?

YesNo

How did you hear about us?

VeterinarianFriendWebEventOther:

I give Burlington Emergency & Veterinary Specialists permission to take photographs of my pet for the purpose of posting on Burlington Emergency & Veterinary Specialists’ Facebook, YouTube and clinic website.

YesNo

PET INFORMATION

Reason for Visit:

Name

DogCatOther:

Breed:

Color:

Gender:

MaleFemaleUnknown

Spayed / Neutered:

YesNoUnknown

Date of Birth / Age:

Current Medications:

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. 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