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When Is Your Appointment?
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Name of Pet Owner or Guardian
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First*
Last*
Address:
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Street*
City*
State*
Zip Code*
Contact:
Cell
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Email Address
*
How Did You Find Us?
Referred By:
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Pet Store/Groomer/Day Care/Hospital
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Customer
Name of Referring Customer:
Patient Information
Pet's Name
Species
*
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Feline
Canine
Breed
Color
Sex
Male
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Age
Spayed/Neutered?
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Yes
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Disclaimer
*
I hereby authorize the staff of Fort Lee Animal Clinic to render any treatment deemed necessary to my pet's wealth while in the hospital's custody.
I understand that in any unusual or emergency circumstance, the staff will make every attempt to contact my designated representative or me before, if time permits, proceeding with treatment.
I understand that I will be financially responsible for all emergency procedures, including the Estimate of Charges provided to me in person or over the phone. I understand that professional fees are to be paid at the time services are rendered.
I agree per the above policies.
Email Consent
I agree to receive recurring automated messages about pet care, appointment reminders, marketing communications, and offers to the mobile number provided. Your consent is not required, and you may opt out at any time by replying STOP. Msg & data rates may apply. Message frequency may vary.
I agree to receive email communications.
SMS Consent
I agree to receive recurring automated messages about pet care, appointment reminders, marketing communications, and offers to the mobile number provided. Your consent is not required, and you may opt out at any time by replying STOP. Msg & data rates may apply. Message frequency may vary.
I agree to receive SMS communications.
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