Owner Information

Owner Information

Pet Information

Referral Information

I assume all responsibility for all charges incurred in the care of this animal. I understand that there is a consultation fee that is due at the time of service. I understand that a deposit of 75% of the highest end of any estimate given will be required before the treatment of my pet. I also understand that the bill must be paid in full at the time of release of my pet. (We may need to make a photo copy of your driver license for our chart.)

I grant to Affiliated Veterinary Specialists, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically.

I agree that Affiliated Veterinary Specialists may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and Web content.