Name:                               Social Security Number*

Address:             City:

State:       Zip Code:           Home Phone:

Cell Phone: Pager:      Driver's License*

Employer:                           Work Phone:

Spouse/Alternate Contact: Social Security Number:

Address (if different): City

Cell Phone: Pager: Driver's License*

Employer: Work Phone:

(* To pay by check, we must have a driver's license and social security number on file*)

E-Mail Address:

Would you like to be contacted by e-mail for your pet's vaccination reminders? Yes No

Please Tell Us About Your Pets

Previous Veterinarian or Clinic:

How Did You Hear About Our Clinic?

Sign

Yellow Pages

Advertisement/Coupon

Referred by:
(We offer a $10 credit for your referral)

Other (Please specify)

Important Information:

Payment is expected when services are rendered . How do you plan to pay your account?

Cash Check Visa Mastercard American Express Discover

(*To pay by check, we must have a driver's license and social security number on file*)

1. I hereby authorize the doctors and staff of Sawnee Animal Clinic to examine, prescribe for
and treat the above pets.

2. I understand that I may request an estimate at any time prior to services being performed
(estimate only good for 30 days!).

3. I am the legal owner of the above pets and will assume responsibility for all charges incurred
in their care.

4. I understand that there is a $25 return check fee and that the clinic charges a 1.5% billing
fee for statements.

I do hereby agree to the above statements and declare all above information to be accurate
to the best of my knowledge.

Signature (type in name): Date (type in date):