Requested Procedures: Purchaser please check the box for each procedure you would like performed (select all that apply):
If you will not be present at the time of exam, please list the name and telephone number of your representative below.
Payment Terms: Unanticipated services may incur additional costs. Pre-Purchase Examinations cannot be scheduled until Green Mobile Veterinary Services has your credit card information and authorization; please call our office with that information or submit with this form.
By submitting this form and information, I understand that I am responsible for payment of the above procedures and treatments at the time of service. I authorize Green Mobile Veterinary Services to charge my invoice in its entirety to the above referenced credit card.