All fees are due at time services are rendered

Please indicate choice of payment *

—Please choose an option—CashVisa / MastercardDiscover

How did you become aware of our clinic? *

—Please choose an option—Online SearchSignPhone bookValpakWord-of-MouthOther

If Other, please specify:

****PET 1****

Heartworm/Flea Prevention *

—Please choose an option—YesNo

Sex: Spayed or Neutered? *

—Please choose an option—FemaleMaleFemale/SpayedMale/Neutered

****PET 2****

Heartworm/Flea Prevention

—Please choose an option—YesNo

Sex: Spayed or Neutered?

—Please choose an option—FemaleMaleFemale/SpayedMale/Neutered

****PET 3****

Heartworm/Flea Prevention

—Please choose an option—YesNo

Sex: Spayed or Neutered?

—Please choose an option—FemaleMaleFemale/SpayedMale/Neutered

PERSON TO CONTACT IN CASE OF AN EMERGENCY

I accept the terms: *

All fees are due and payable upon release of patient. If the patient has to be admitted for treatment, a deposit will be required at that time.

"I give Affordable Pet Hospital permission to obtain my pet's medical records from other animal hospital's and also give my pets medical history to other veterinarians whenever necessary."

Please leave this field empty.