WELCOME TO GOVERNOR ANIMAL CLINIC

Thank you for giving us the opportunity to care for your pet. Please print in all spaces, and fill out form completely. All information will be confidential.

Date                                                 

Your Name                                                                                                     Your Date of Birth_____________________________
                                                                                                                                              (DEA requirement for dispensing controlled drugs)

Spouse/Partner                                                                                              Your children's names_____________________________________

Address                                                                                                                  

City                                                                State                                   Zip                       

Home Phone                                                    Cell Phone _____________________________

Employer                                                                                                Work Phone_____________________________

Occupation                                                                                           

Emergency Phone                                                                                 

Spouse/Partner Employer                                                                          Work Phone______________________________    

Cell Phone                                                                                          

Drivers Licence#                                                                                _

E-mail Address                                                                              May we send you email reminders for your pet?  yes___  no___

Please give 24 hours notice if appointments cannot be kept

We will gladly prepare a written estimate if you desire. This will be important to you since all professional fees are due at the time services are rendered.   Although we do not offer billing services, we take Master Card, VISA, Discover and American Express. Please ask us about our Care Credit if you wish to arrange financing.

There will be a $25.00 service charge for any check returned unpaid.

PLEASE NOTE:    Hospital personnel are not here 24 hours a day. Veterinary services are provided during nighttime hours as deemed necessary by the veterinarian in charge.

ALSO: Should this account become delinquent, I understand that I am responsible for any and all legal fees, court costs and collection charges involved as a result of any collection activity.

Print Name  ________________________________  Signature of responsible agent for pet(s) ___________________________________________

                                                                                                                                                              Date                                   

 How did you first hear about us? (please be specific)                                                                                   

   ESSENTIAL PET INFORMATION

PLEASE LIST ALL PETS AT HOME and include this information for each one;

Pet's Name                                          Cat/Dog                     DOB                         Sex /Altered                      Breed/color

Have any of the pets listed above ever shown any signs of aggression ? yes       no      towards people            other animals            

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