Name *

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Spouse's Name

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Address

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Home Phone *

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Email *

Where did you learn of our hospital?

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Pet's Name *

Date of Birth *

Species *

Cat
Dog

Breed *

Color *

Sex *

Male
Female
Neutered Male
Spayed Female

Where was pet obtained? *

Reason for Visit *

Any known allergies? *

Most Recent Date of Rabies Vaccine

Most Recent Date of Distemper Vaccine

Most Recent Date of Heartworm Test

Most Recent Date of Bordetella Vaccine

Most Recent Date of Rabies Vaccine

Most Recent Date of FVRCP Vaccine

Feline AIDS/Feline Leukemia Test Performed?

Yes
No

Authorization *

I hereby authorize the veterinarians and staff of St. Georges Veterinary Hospital to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for any and all charges incurred in the care of this animal. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICES RENDERED OR RELEASE AND THAT A DEPOSIT IS REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. A billing fee and finance charge will be applied to all accounts unpaid after 30 days. The finance charge is computed by a periodic rate of 1.50% per month, which is the annual percentage rate of 18.00%, with a minimum charge of $1.00.

Signature *

Date *

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