New Client Form in Buckeye, AZ | Marketside Animal Hospital at Verrado

Name*

First Last

Additional Owner

Phone*

Cell Phone

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Veterinarian office we may call to get pet records

Pet Information

Name:*

Species*

Cat
Dog

Date of Birth or Age*

Breed*

Color*

Sex*

Male
Female

Spayed / Neutered*

Yes
No
Unsure

Additional Pet (Optional)

Name:

Species

Cat
Dog

Date of Birth or Age

Breed

Color

Sex

Male
Female

Spayed / Neutered

Yes
No
Unsure

Please read the following statements:

This veterinary premise does not have the personnel to provide 24‐hour observation to our patients. At your request, we can refer you to an emergency clinic for 24‐hour care and treatment.

Please be advised that you are welcome to purchase prescription medications from our hospital or take a written prescription.

To prevent the spread of infectious disease, all hospitalized, surgery, boarding and grooming patients must be current on all vaccines and free of internal and external parasites.

We will gladly prepare a written estimate of service fees, if you desire. All fees are due at time of service. In case of extensive medical procedures or surgery, a deposit may be required. We accept Visa, MasterCard, Discover, debit, and cash.

I agree that Marketside Animal Hospital may use such photographs of my pet with or without the pet’s name for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites.

I have read and understand the preceding statements. I hereby authorize the veterinarian to examine, prescribe for, and treat the above animal. I assume responsibility for all charges incurred for the care of my animal.

Date*

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