New Client & Patient Form | Seven Mile Animal Centre

Client Information

Client Name(s)

Phone Number

Address

Patient Information

Name

Microchip Number

(enter "none" if no microchip)

Date Implanted

Species

Colors & Markings

Breed

Age

Past Veterinary Care Provider(s)

Sex & Status

Last Vaccination Date

Current / Past Medical Conditions

As the caregiver, or authorized agent, of the above named pet, I hereby consent and authorize Seven Mile Animal Centre (SMAC) to provide any and all medical care as they see fit on the above named patient.

I give Seven Mile Animal Centre permission to obtain my pet’s medical history from other veterinary providers. I understand all fees are due and payable upon discharge of the patient. If the patient requires hospitalization, a deposit will be requested at that time.

Signature (by clicking yes you agree to the above)

Yes

Date

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