Owner Name* First Last Date* Date Format: MM slash DD slash YYYY Pet's Name*Species*DogCatPet Info*AgeMale / FemaleBreed / ColorPreferred Phone*Emergencies Only Phone*Description of ConcernsProcedure I authorize this procedureLab Work (Only as Necessary)By signing this, you understand that we will only try to contact you once with a treatment plan for your visit. If we are unable to reach you, the doctor will proceed with the diagnostic they feel is best. Any and all medications will be reviewed at the time of pick up. We will not be able to release any medications without the full payment. You understand that you will only be in contact with the registered veterinary technician unless the doctor suspects a follow up is necessary. At the time of follow up you will be told to schedule an in-room appointment. The drop off physical exam is $35. . I assume all financial responsibility for all services rendered and payment will be expected at the time of the patient’s release.Signature of Owner / Agent*Dog Optional Items Rabies Vaccine ($15) Distemper Parvo Combo Vaccine ($16) Leptospirosis only ($16) Bordetella Vaccine ($16) Influenza Vaccine ($28) Microchip ($35) Heartworm Test / Flex 4 ($30) Nail Trim (Free) Cat Optional Items Leukemia Vaccine ($21) FIV / Leukemia Test ($36) Fecal ($15) Influenze Vaccine ($28) Upper Respiratory Combo Vaccine ($16) Microchip ($35) Nail Trim (Free) Please bring any medical records with you. All cats should be in carriers.