Client InformationName First Last Date MM slash DD slash YYYY 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 Cell PhoneSecondary PhoneDriver's License:Email *An updated Rabies vaccine is required at the time of the exam or can be performed during the exam or prior to surgery for the day! Spouse or other contact information: (Must be over 18 years old to authorize treatment) Do you carry CareCredit credit card? Unlike traditional pet financing the CareCredit credit card gives you the flexibility to use your card again and again for your pet’s procedures. You can apply here at Jackson Hwy Vet Clinic, just ask a receptionist how!Name First Last Cell PhoneSecondary PhoneRelationshipEmergency ContactPhoneRelationshipConsent I hereby authorize the Veterinarians at Jackson Hwy Vet Clinic to examine, prescribe for, and or to treat my pets. I also agree that the above information is true.Consent I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED IN THE CARE OF MY PETS. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICES RENDERED AND THAT 50% DEPOSIT WILL BE REQUIRED FOR COMPLICATED AND OR SURGICAL TREATMENTS.SignatureDate MM slash DD slash YYYY Name First Last CAPTCHAΔ
