PLEASE PRINT, FILL IN AND BRING THIS FORM & YOUR VOUCHER WITH YOU TO OUR OFFICE FOR

ALL SPOT NEUTERS & SPAYS

 

Last Name: _______________________ First Name: ______________________ Date: ___________

Address: ___________________________Apt.#____ City: _____________State: _____Zip: _______

Home Phone: __________________________ Work: ___________________Cell: ________________

Emergency Contact Name:_____________________ Relation:____________Phone:______________

Email Address:______________________________________________________________

We accept: Cash, Credit and Debit cards.

Patient Info:

Pet Name:_______________CAT o DOG o Male o Female

Breed: ____________________ Color: ______________ Date of Birth/Age: ____________

 

What would you like done today – please put a check mark R by the desired services:

Spay (females) o               Neuter (males) o              

Physical Exam $20 o

Pain Medicine $25 o 

Antibiotics $15 o     

Elizabethan Collar $15 o

Heartworm Test (dogs)$25 o     FeLV/FIV Test (cats) $25 o        Fecal $15 o

Rabies 1 year $11 o         Rabies License $8 o

DHPPC (dogs) $11 o                              

Bordetella     (dogs) $11 o                               

FVRCP (cats) $11 o                    

FeLV (cats) $14 o             

Dental Cleaning $85 o

Flea Treatment $16 o

Dew-Claw removal $60 o

Ear cleaning $5 o          

Nail Trim $5 o

Microchip $20 o

Anything else_____________________________________________________________________

I have authorized the above checked services and have declined the rest and I agree to pay

in full for these services at time of treatment:

Owner’s signature____________________________________________