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    --- All entries marked with an "*" are required ---

    OWNER INFORMATION:

    AUTHORIZED REPRESENTATIVE OF THE OWNER (if owner not present)

    PET INFORMATION

    REFERRAL INFORMATION:

    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.

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