--- All entries marked with an "*" are required --- OWNER INFORMATION: Date of Appointment* Title Mr.Mrs.Ms.Dr. Owner's Last Name* Owner's First Name* City* State & Zip* Zip Code* Cell Phone* Home Phone Emergency Number* Email Address* Employer* Employer Address* Employer City* Employer State & Zip* Pet Insurance Company AUTHORIZED REPRESENTATIVE OF THE OWNER (if owner not present) Title Mr.Mrs.Ms.Dr. Last Name* First Name* City* State & Zip* Cell Phone* Home Phone Emergency Number* Email Address* Employer* Employer Address* Employer City* Employer State & Zip* PET INFORMATION Pet's Name* Species* DogCatOther If Other Breed* Sex* MaleFemale Neutered/Spayed* YesNo Color* Weight* Date of Birth* REFERRAL INFORMATION: Name of Primary Veterinarian and/or Facility* Address and/or Phone* 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. Today's Date [recaptcha] By clicking the send button, you agree to the conditions above:
