Primary Owner: |
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Home Phone Number: (required)
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Cell Phone Number: (required)
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E-Mail Address :
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Best way to contact you during the day? (required)
Home Phone Number
Cell Phone Number
Text Message
Email
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Best way to contact you after business hours? (required)
Home Phone Number
Cell Phone Number
Text Message
Email
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Occupation:
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Place of Employment:
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Work Phone Number:
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Spouse/Co-Owner: |
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Relationship to Primary Owner: (required)
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Home Phone Number: (required)
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Cell Phone Number: (required)
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E-Mail Address (required) :
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Best way to contact you during the day? (required)
Home Phone Number
Cell Phone Number
Text Message
Email
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Best way to contact you after business hours? (required)
Home Phone Number
Cell Phone Number
Text Message
Email
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Occupation:
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Place of employment:
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Work Phone Number:
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Pet Information: |
Pet's Name: (required)
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Age: Years, Months:
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Species: (required)
Canine
Feline
Avian
Exotic
Other
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Breed:
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Sex: (required)
Male
Female
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Neutered/Spayed?
Neutered
Spayed
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Are your pets vaccines current?
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Do you have pets medical records?
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Medical records at another veterinary Practice?
Yes
No
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Name of Former Veterinary Practice
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May we request a transfer of records?
Yes
No
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Please list any additional pets here:
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(required)
I, the undersigned, and owner or authorized agent of the above mentioned pets, do hereby authorize The Animal Hospital of Lynchburg to perform such examinations, diagnostic tests and treatments as necessary. I further agree to be financially responsible for all costs for such procedures and treatments. I understand that full payment is due at time of service. I understand that abandonment of animals does not relieve me of this financial obligation. Failure to pay bills on time may results in billing, finance charges and/or costs of any collection fees incurred.
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Please type first and last name: (required)
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Date (mm/dd/yyyy): (required)
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How did you hear about us? (required)
Yellow Pages
Hospital Sign
Website/ FaceBook
Magazine Advertisement
Personal Recommendation
Other
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If other, please list below:
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If personal recommendation, whom may we thank?
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Media Release: |
Selection (required)
I hereby grant the Animal Hospital of Lynchburg the right to use the name and photograph or radiograph of my pet in connection with its promotional materials in any and all media, including print material, internet and film.
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Please type first and last name: (required)
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Date (mm/dd/yyyy): (required)
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