EmailThis field is for validation purposes and should be left unchanged.We know your pet's health is important, and we appreciate you for trusting us to care for them. To help us provide the best care possible, please take a few moments to complete this form. Thank you!Owner InformationName* First Last Phone*Secondary NumberEmail* Address* Street Address City State / Province / Region ZIP / Postal Code Mailing Address If Different Street Address City State / Province / Region ZIP / Postal Code Reminder Preferences: Email Text Message Phone Call Mail Select all that apply Pet InformationPet Name*Species* Dog Cat Breed*Color*DOB/Age*Sex* Male Female Unknown Spayed/Neutered* Yes No Reason For VisitIs your pet up to date on Vaccinations? If so please provide vaccination certificate.* Yes No Any signs of illness today?* Yes No If yes please discribeHas your pet had any previous reactions to anesthesia?* Yes No I verify I am the owner or authorized agent for the above named pet.* I authorize High Prairie Veterinary Services permission to examine, prescribe for, and/or treat my pets. I accept the risk inherent in any anesthesia or surgery and release HPVS of any liability associated with the procedure. I further understand that there may be additional, deemed necessary, treatment or expenses upon further examination and commencement of my pet’s treatment plan. If my pet has fleas, ticks, mites, or internal parasites, I authorize treatment for removing them. I accept responsibility for all charges associated with the care of all the pets on my record. I am aware that these charges must be settled at the time of the pets' release, and I acknowledge that a deposit may be necessary for surgical treatment or hospitalization. Additionally, I understand and agree to a 10% billing charge monthly, as well as the obligation to cover any collection charges including up to 40% for outstanding balances. I understand that if I am unable to pay for services or products in full at time of service, I must make prior arrangements to settle my account. Payment is due at time of service. By signing below I affirm that I have read and understood everything on the form.Date* MM slash DD slash YYYY
