Happy Paws House Calls
Wellness / Sick Visit Appointment Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Pets Name (1st pet)
*
Species
*
Dog
Cat
Color
*
Age
*
Gender
*
Neutered Male
Male
Spayed Female
Female
Any known allergies. (Please list all. If none, please type N/A)
*
Reason for appointment.
*
Please attach your pets records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Pets Name (2nd pet)
Species
Dog
Cat
Color
Age
Gender
Altered Male
Unaltered Male
Altered Female
Unaltered Female
Any known allergies? Please list all. If none type N/A
Reason for appointment? (Please describe if your pet is sick)
Please attach your pets records
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Cancelation, Policy and Authorization
Please read and agree for each of the following statements. By initialing below you are agreeing to all statements. By you agreeing and initialing below it is as legally binding as your physical signature.
Appointment Cancellations - I understand if I cancel an appointment with less than a 24 hours notice, I will be charged the cancellation fee of $50.00
*
I agree
Treatment/Payment Authorization - I understand every effort will be made to achieve a successful outcome for my pets treatment. I certify that I am 18 years of age or older and I assume all financial responsibility for charges incurred. I understand and agree to pay the charges and that they are due at the time of service.
*
I agree
I hereby authorize Dr. Mandeep Mini, (Happy Paws House Calls) to treat my pet(s) and furthermore understand that unforeseeable, adverse reactions to treatments are always possible and I authorize treatment necessary should any reactions occur.
*
I agree
By initialing below, it is legally binding as your physical signature.
*
Submit
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