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CLIENT INFORMATION

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Secondary Owner's Name







Address


















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We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept debit, VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, AND CARE CREDIT. If you plan to use a credit card or Care Credit, please provide your driver’s license to the receptionist to make a copy.

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To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites to enter our hospital for surgery, boarding, drop off or hospitalization.

I hereby certify that I am the legal owner of the below-listed pet(s) and accept full financial responsibility for their treatment and care. I authorize the doctors of Haines Road Animal Hospital to provide medical treatment, vaccines, and parasite control for my pet(s).

PET 1 INFORMATION


MM slash DD slash YYYY

Spayed or Neutered?


PET 2 INFORMATION


MM slash DD slash YYYY

Spayed or Neutered?


PET 3 INFORMATION


MM slash DD slash YYYY

Spayed or Neutered?


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(727) 470-6949

913 1st Ave N.,
St. Petersburg, FL 33705

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