Willis Vet - New Patient Information

1
Owner's Name
First Name
Last Name
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2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
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Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Bolivia
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Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
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Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
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Senegal
Serbia
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eSwatini
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Tonga
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Isle of Man
US Virgin Islands
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Phone
Alternate Phone
Email
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4
Spouse or Significant Other (First Name)
Spouse or Significant Other (Last Name)
Spouse or Significant Other (First Name)
Spouse or Significant Other (Last Name)
Phone
Alternate Phone
Email
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5
How did you find out about us?(Mark ALL that apply)
Billboard
Kroger Grocery Cart
Drive By
Personal Recommendation
Internet Search / Website
Review It magazine - The Woodlands
Review It magazine - Lake Conroe
Saw us at an event
Facebook
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6
Whom may we thank
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7
What event?
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8
FINANCIAL RESPONSIBILITY/ POSSESSORY LIEN* This field is required
Stone Ridge Veterinary Medical Center I understand that I assume financial responsibility for all services rendered. I further agree to pick up my pet at the designated time and to pay in full all services rendered. I also understand that my pet will not be released until the balance is paid in full. If my pet is not picked up as agreed, a written notice of abandonment will be mailed to me. Twelve days after the notice is issued, my pet will be considered abandoned and may be disposed of in a manner deemed appropriate by Stone Ridge Veterinary Medical Center. By signing this document, I attest that I have read and agree to the aforementioned conditions
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9
TREATMENT AUTHORIZATION* This field is required
I understand that every effort will be made to achieve a successful outcome and to provide safe in-hospital care and handling. I hereby authorize this veterinary facility to receive, prescribe for, treat, or perform surgery upon the pet listed on the form with my consent. Furthermore, I agree to pay fees for services rendered at the time of service. I agree to pay for the costs of collection in the event that collection efforts become necessary. I understand that veterinary service is provided during nighttime hours only at the local emergency clinic. Continuous of qualified personnel during nighttime hours are not provided at this clinic.
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10
TO HELP PREVENT THE SPREAD OF INFECTIOUS DISEASE, ALL HOSPITALIZED, BOARDING, AND DROP OFF ANIMALS MUST BE CURRENT ON ALL VACCINATIONS AND FLEA FREE.

BY SIGNING THIS DOCUMENT, I ATTEST THAT I HAVE READ AND AGREE TO THE AFOREMENTIONED CONDITIONS.
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11
Signature
Clear
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12
Pet(s) Information
Name of Pet
Pet’s DOB or Age
Species
Gender
Spayed / Neutered
Breed
Color
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13
Give the date that the following vaccinations or procedures were last performed
List any previous surgeries your pet has had
List any previous or current illnesses
List any medications your pet is taking
List any allergies to medications or vaccines
List any special diets your pet is on
List any other information that you feel the doctor should know
List any other information that you feel the doctor should know
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