Owner Information Form Contact InformationPrimary Owner* First Last Phone*Email* Phone Type*HomeMobileWorkSecondary Owner First Last PhoneEmail Phone TypeHomeMobileWorkPrimary Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Alternate PhonePhone TypeHomeMobileWorkOther Permissible ContactsThe following people will be added to your account & have access to your pet’s medical information.Name First Last RelationOther FamilyFriendPet SitterPhonePhone TypeHomeMobileWorkName First Last RelationOther FamilyFriendPet SitterPhonePhone TypeHomeMobileWorkReferring Veterinarian InformationDoctor’s NamePrimary Care VeterinarianClinic NameDoctor’s NameReferring Veterinarian – if different from aboveClinic NamePet’s InformationPet’s Name*Breed*Species*CanineFelineDate of Birth*Sex*MaleFemaleColor*Altered*YesNoReason for visit?*List any known drug allergiesConsent*I authorize and direct the veterinarians at Desert Veterinary Medical Specialists to examine, diagnose, prescribe, perform therapeutic procedures and/or surgery that their judgement may dictate for the patient’s care and well-being. No warrant to guarantee has been made as to the result or cure. ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. We accept cash, all major credit cards, GE Care Credit, and check. A driver’s license is REQUIRED if you plan to pay by check. If you choose not to disclose this information, only cash or credit cards will be accepted. There will be a service charge for any returned checks. A deposit is required at the time of admission and the balance paid in full at discharge. If you have nay questions about the fees or the financial policy, please alert a front desk staff member before services are performed. Accounts not paid within 30 days are subject to a finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all costs included in the unpaid balance including reasonable collection / attorney’s fees. Arizona Veterinary Specialty Center is comprised of multiple practices within the building. Charges that are assessed for your pet will be billed separately through each practice. If you have nay questions, please be sure to ask one of our front desk staff members. I agreeSignature of Responsible Party*(Must be over 18 years of age)Date* Date Format: MM slash DD slash YYYY