Address (street address, city, state zip):
Place of Employment:
Best Time to Reach You:
All Fees Are Due At The Time Services Are Rendered
Choice of Payment:
How did you become aware of our clinic?
If Personal Recommendation, Whom May We Thank?
Date of Birth
Preventative Health History:
Vaccines given (date), fecal/stool sample (date)
Heartworm test (dogs)
Heartworm preventative (dogs)
Any Previous Serious Illnesses or Surgeries?
Any Allergies to Vaccines or Medications?
Is Your Pet on Any Special Diets or Medications?
Disclaimer (to be signed at your first visit):
I have provided information that is true and correct to the best of my knowledge. I hereby give Graham Veterinary Clinic permission to examine and treat my animal. Payment is due upon completion of visit. Graham Veterinary Clinic accepts cash, checks, and credit cards. If legal action is necessary to collect outstanding fees, I agree to be obligated for all collection fees incurred, including but not limited to filing fees, court cost & attorney or agent fees. Any animal left more than 10 days after the completion of services will be considered abandoned and will become property of the Graham Veterinary Clinic. Graham Veterinary Clinic will have sole discretion over what to do with the animal.