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STAFF USE ONLY Aquia-Garrisonville Animal Hospital CLIENT ID INITIALS New Client & Patient Information Home Telephone: ( ) ____________ - ___________________ Owner’s Name: ___________________________________________________________ Driver’s License #: __________-_______-__________* Issuing State: ________* Exp. Date: _______ /_______ / _______* Street Address: ____________________________________________________________ City: _______________________________________ State: __________ Zip: ___________________ Employer: ___________________________________ W#: ( ) _______-__________ C#: ( ) _______-__________ Spouse/Other: ___________________________________________________________ Employer: ___________________________________ W#: ( ) _______-__________ C#: ( ) _______-__________ Driver’s License #: __________-_______-__________* Issuing State: ________* Exp. Date: _______ /_______ / _______* How did you learn about us? Sign Website Newspaper Yellow Pages Other:________ Friend: _________________________ *This information is required in order to pay with a check, and will remain confidential. 1st Pet Pet Information 2nd Pet Name: Species: Breed: Color/Markings: Sex: (S=Spay / N=Neuter) M M/N F F/S M M/N F F/S Date of Birth: Known Drug Allergies/Problems: Vaccine Information: To prevent the spread of infectious diseases and external parasites, hospitalized animals MUST BE CURRENT ON ALL VACCINES AND FREE OF EXTERNAL PARASITES. I authorize Aquia-Garrisonville Animal Hospital to provide vaccines and parasite control when needed. Full payment is expected when services are rendered. Deposits are expected on medical / surgical cases and emergency work where hospitalization is required. We accept the following as methods of payment: CASH / CHECK / VISA / MASTERCARD / DISCOVER (NOVUS) / CARECREDIT ** The current state allowable charge will be assessed for any returned check. In the event of any default of payment, I agree to pay all collection and court costs, including attorney’s fees in the amount of forty percent (40%) of the total indebtedness. ** X______________________________________________Date_________________________ Signature of Owner or Authorized Representative