Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

How did you hear about us?

Your Cell Phone *

OK to Text?

Yes
No

Alternate Phone

Name of Spouse or Other Contact

Spouse Phone

OK to Text?

Yes
No

I consent to have photos of my pet posted on Facebook and Instagram:

Yes, I consent.
No, I do not.

Pet 1 Name *

Breed *

Age or DOB *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Add additional pet? *

Yes, add additional pets
No, no additional pets

Pet 2 Name *

Breed *

Age or DOB *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Add additional pet? *

Yes, add additional pets
No, no additional pets

Pet 3 Name *

Breed *

Age or DOB *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Signature *

Payment is due in full at the time services are rendered. We accept cash, checks, all major credit cards, Care Credit, and ScratchPay. A $30.00 service charge will be applied to any checks returned unpaid. Any accounts having a balance will be charged a service fee of 1.5% per month (18% per annum). In the event of a default where it becomes necessary to place this account in the hands of a third party for collection, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees and court costs. I have read and understand the above statements and agree to all terms therein.

Date *

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