Buies Creek Veterinary Clinic (Form)

Today’s Date

Address

City

State

Owners Name

Home Phone

Cell Phone

Zip Code

Spouse Cell

Employer

Email Address

Spouse Name

In case of an EMERGENCY who can we call?

Business Phone

Appointment Date

Pet Information

How did you hear about us? How did you hear about us? Internet Driving by Sign Friend (Name) Other

Age/Birthday

Pet Name

Breed

Species (cat or dog)

Color

Gender: Male or Female

Spayed/Neutered? Spayed/Neutered? Yes NO

Has your pet had a reaction to vaccinations or medications? Yes, No, If so What?

Current Medication

Is your pet on heartworm prevention? If so what?

When was your pet’s last rabies vaccine?

Previous Vet

Contact Number of previous vet

Reason for today’s visit?

Authorization: I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet. I assume responsibility forall charges incurred in the care of this animal. I also understand that these charges will be paid at the time release and thata deposit may be required for surgical treatment.*Pictures taken of your pet may be posted on our facebook page.

Signature of owner or agent ( Type in your Full Name )

Date