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Client /Pet Information Form Atlantic Animal Clinic 7620 N. Atlantic Ave Cape Canaveral, Fl. 32920 Phone 321-784-4248 Fax 321-784-4340 Dr. Christine M. Storts Dr. Elizabeth Kezer CLIENT-INFORMATION Date: Name _______________________________ Spouse Name __________________________ Address _____________________________ Social Security#________________________ City ______________________ Zip ______ Home & Cell Phone_______________
Employer ___________________________ Work Phone _________________ PET INFORMATION: (Please list all pets in household) Name Species Breed Color Date of Birth Sex Spayed/Neutered Date Last Vaccines
1.____________________________________________________________________________________ 2.____________________________________________________________________________________ 3.____________________________________________________________________________________ 4.____________________________________________________________________________________ Where was pet(s) last kind of veterinary treatment? Date / Veterinarian / Phone Number _____________________________________________________ Our typical Canine Annual consists of: Rabies, DA2PP, Bordetella, and Lyme Vaccines, Heart Worm Test and Fecal. Our typical Feline Annual consists of: Rabies, FVRCP, FELV Vaccines and Fecal. Please let us know if you choose to have your pet's treatment administered differently.
PAYMENT INFORMATION: Service Fees are to be paid at time they are rendered. Please circle method of payment. CASH DEBIT MC VISA DISCOVER CHECK - LOCAL CHECKS ONLY!!
Please allow us to photocopy your driver's license for identification purposes. (Please present driver's license to receptionist for copying, along with this completed form.)
Upon your request, we will provide you with a written estimate of fees for any treatment, emergency care, surgery, or hospitalization that will be provided. A deposit prior to treatment may be required depending on amount of estimate. All fees are due at the time the patient is released. There will be a fee for all returned checks. The client agrees to pay a reasonable fee and all costs if Atlantic Animal Clinic must pursue action to collect any fees due for treatment or services. Client’s Signature: ___________________________________________________________
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