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Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Pet Information

Medical History

Statement Of Ownership

By checking below you certify that you are the owner and or agent of the above animal and you also authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). You also certify that you will assume responsibility for all charges incurred and that these charges will be paid at the time services are rendered.

Office Use Only: ______entered _______logged