Client Form

 

COMPANION ANIMAL’S INFORMATION

Date of last Vaccines:

Date of last Vaccines:

AUTHORIZATION AND FINANCIAL RESPONSIBILITY AGREEMENT



I hereby authorize Dr. Landis to examine, prescribe for and treat the described pets. I assume responsibility for all authorized charges incurred in the care of this animal. Payment may be made with cash, check or credit card (Visa, MasterCard, Amex and Discover accepted). PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED.