CLIENT INFORMATION

Radio Newspaper Television Magazine Drove by office Phone Book Prescott/Prescott Valley Online Local Pages Word of Mouth Other

PATIENT INFORMATION

Dog Cat Other
M F
Yes No

PATIENT HISTORY

Medical Records Provided Medical Records
I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet(s). I assume responsability for all charges incurred in the care of my pet(s). I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.