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Address
Preferred Method of Contact
How did you first hear of our hospital?

Animal Information/Medical History

Pet 1
Species: Feline (cat) Canine (dog) Exotic
Breed (type):
Color
Date of Birth:
 
Sex
Pet 2
Species: Feline (cat) Canine (dog) Exotic
Breed (type):
Color
Date of Birth:
 
Sex
Pet 3
Species: Feline (cat) Canine (dog) Exotic
Breed (type):
Color
Date of Birth:
 
Sex

Notification/ Agreement

To prevent the spread of infectious diseases and parasites, hospitalized and medical boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the New Prairie Small Animal Clinic to provide vaccines and parasite control as needed for my pet. I am financially responsible for the patient(s) described above and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee that successful outcome of any such procedure. This agreement is in force indefinitely from this date unless notify New Prairie Small Animal Clinic in writing on the contrary.

Authorization for release of medical records.

I authorize the New Prairie Small Animal Clinic to acquire any and all medical or surgical records from my previous veterinarian and /or send such information to any veterinarian and/or pet boarding/ grooming facility as requested by us or them.

PHOTO CONSENT

I grant to New Prairie Small Animal Clinic, its representatives and employees the right to take photographs of me/ or my pet, and to copyright, use and publish the same in print and or electronically. I agree that New Prairie Small Animal Clinic may use such photographs of me and or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

Payment Information

  • Payment is due in full at the time services are rendered
  • This office does NOT do any billing, we do NOT offer payment plans
We accept the following forms of payment:
  • Visa
  • MasterCard
  • Discover
  • American Express
  • Care Credit
  • Cash
We accept personal checks with a valid Driver’s License or Social Security Number. There is a $25 fee for all returned checks. Please print and sign below that you are taking responsibility for full payment of treatment and services for the pets you are bringing in to New Prairie Small Animal Clinic, at the time they are treated. If you are not the individual who is financially responsible for these pets, by signing this form you are stating that you have made prior arrangements with the individual who is. I agree to absolve the New Prairie Small Animal Clinic, veterinarian, and staff employed by the practice of any financial consequences that may occur between you and the other individual you have made prior arrangements with.
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