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FEEDER CREEK VETERINARY SERVICES
12575 MILLERSPORT RD*MILLERSPORT, OH 43046
(740) 467-2949
Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information we will need as we support your pet’s needs today and in the future. Please fill in all spaces.
YOUR NAME______________________________________________________
EMAIL ADDRESS__________________________________________________
ADDRESS____________________________CITY________________________
COUNTY__________________ STATE__________ ZIP___________________
HOME PHONE (____)______-________WORK PHONE (____)____-________
EMPLOYER_______________________________________________________
SPOUSE/ OTHER___________________________________________________
EMPLOYER_______________________WORK PHONE (____)____-_________
OTHERS AUTHORIZED TO USE ACCOUNT____________________________
In the event my pet is lost, I give the staff of Feeder Creek Veterinary Service, Inc. my permission to release my personal information (please check your preferences- Name___, Phone number___, and /or Address___) to the person calling who has found my pet.
Signed,__________________________________________________Date__________________
We will gladly prepare a written estimate if you desire ( please ask the veterinarian or receptionist). This will be important to you since payment in full is required at the time of service. We take Master Card, Visa, Discover, American Express, and personal checks. In cases of extensive medical of surgical procedures, when full payment may be difficult, arrangements can be made to hold checks (not post-dated) if approved in advance of treatment. There will be a $30.00 service charge for any check returned unpaid.
SIGNATURE OF RESPONSIBLE AGENT________________________DATE__________
HOW DID YOU FIND OUT ABOUT US?
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___OTHER (PLEASE SPECIFY)_______________________________________________ |
