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Pet
Information
Pet #1:
Name:
Sex:
Breed:
Age (yrs):
Pet #2:
Name:
Sex:
Breed:
Age (yrs):
Veterinarian Information
Vet's Name:
Address:
Telephone number:
Emergency
Contact Information
Name:
Address:
Telephone
number:
Special Instructions/Remarks:
By submitting this form:
"I
am giving Georgina Mitchell permission to utilize the
veterinarian listed above if my pet becomes sick while
in her care. I also give
their office permission to bill me for the
visit."
"I give Georgina Mitchell permission to give my first
name and telephone number to prospective clients, to be
used as a business
reference."
Client
Name:
Date:
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