Click here to download & print Date* MM slash DD slash YYYY Owner’s Name* First Last Spouse’s Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Work PhoneEmail Address* Place of Employment* Driver’s License #* DOB* MM slash DD slash YYYY Emergency Contact Name* First Last Emergency Contact Phone*For the Pet SalonVeterinarian Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAdditional InformationHow did you hear about us?* Referred by one of our clients Puppy Store Breeder Professional Referral Personal Recommendation Please enter name* Puppy Store:* Breeder:* Professional Referral:* Personal Recommendation:* Pet's InformationPet’s Name* Species* Cat Dog Bird Reptile Ferret Rabbit Hamster Guinea pig Gerbil Breed* Age* Date of Birth* MM slash DD slash YYYY Color* Sex* Male Female Spayed/Neutered?* Yes No Acquired From* Date Acquired* MM slash DD slash YYYY Other Pets*Upload Documents Drop files here or Select files Max. file size: 128 MB. I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that a deposit of 50% will be required for surgery, hospital, or medical procedures, and that payment in full is required at the time of release, or as services are rendered. Should a portion of my pet’s care be covered, through a prior agreement, by any third party, I also understand that I am responsible for any remaining fees. I understand that I can receive a written fee estimate if I request one. Should the Clinic have to institute collection proceedings to recover any amount owed by me that includes balance due, interest and billing fee’s, I agree to pay all costs of such collection proceedings, including any legal fees incurred. If there is an insurance policy on this pet, the insurance policy is between me and my insurance carrier not the Clinic’s insurance carrier and Commack Veterinary Center. Balances overdue will incur interest and billing charges.* I Agree Signature*Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
