Owner's Name(Required) First Last Best Contact Phone Number(Required)Spouse/Other First Last Secondary Phone NumberAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) **All reminders and appointment confirmations will be sent via email.**How did you hear about us? If referred by an existing client, please list their full name below.Pet Health HistoryPet's Name(Required)Date of Birth(Required) MM slash DD slash YYYY Species(Required) Cat Dog Breed(s)(Required)Color/Marking(s)(Required)Sex(Required) Male Neutered Female Spayed How long have you had your pet?(Required)Where did you get your pet?(Required)Previous Medical Issues/SurgeryCurrent MedicationsKnown Allergies (Include vaccine reactions)(Required)I grant to Jamaica Plain Animal Clinic, LLC, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Jamaica Plain Animal Clinic, LLC, may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. Do we have your consent to post your pet's photo on social media? I give consent I do not give consent AUTHORIZATIONI hereby authorize the veterinarian to examine, prescribe for and/or treat the pet described above. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time services are rendered and that a deposit may be required for surgical treatment. If I need to cancel any scheduled appointment or visit for diagnostic imaging I must give 24 hours notice or a $75.00 missed appointment fee will be charged. I understand that if I am late to a scheduled appointment that I may be required to reschedule and pay the missed appointment fee. If I need to cancel a scheduled surgery I must give 48 hours notice or 20% of the low end of the estimate missed surgery fee will be charged.(Required) I authorize Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ
