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Garden State Veterinary Specialists Client Information Form

Please submit this form no less than 48 hours before your appointment. Thank You.

OWNER INFORMATION
Date of Appt.: (M/D/Y)
Title:
Owner's Last Name:
Owner's First Name:
Spouse's Last Name:
Spouse's First Name:
Address:
City: State: Zip:
Home Telephone:
Cell Phone:
Emergency Number:
E-mail Address:
Employer:
Employer Phone:
Employer Address:
Employer City: State: Zip:
Pet Insurance Company: Policy #:
AUTHORIZED REPRESENTATIVE OF THE OWNER
(If owner will not present for appointment)
Last Name:
First Name:
Address:
City: State: Zip:
Home Telephone:
Cell Phone:
Emergency:
Employer:
Work Number:
Employer Address:
Employer City: State: Zip:
PET INFORMATION
Pet's Name:
Breed:
Species: If Other:
Sex:
Neutered:
Color: Weight: Date of Birth: (MM/DD/YY)
Account #:
REFERRAL INFORMATION
Name of Your Primary Veterinarian and/or Facility:

Address and/or Phone No. (If known):

CONSENT AND AUTHORIZATION
I hereby represent that I am over the age of 18 and authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid when the services are rendered and that a deposit may be required for treatment.
SERVICE CHARGE
In the case of non-payment, I hereby promise to pay an additional fee of 1.5% per month of the outstanding balance on the account together with any collection costs, plus 25% attorney fees, incurred to affect collection of this account. In the case of a returned check, I acknowledge that there will be a fee of $35 imposed by and payable to GSVS.
Date: (M/D/Y)

By clicking the "Send Information" button you agree to the conditions stated above.

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