Action Care Mobile Veterinary Clinic, LLC
Mr.,Mrs.,Miss, Dr. ________________________________________________ Date:___________________
Driverís License or
I. D. Card Number: _______________________ Expiration date:______________________
number and name
] Partner [ ] Co-owner [ ] Name:
did you hear about us?
referral, whom may we thank?
for leaving previous veterinarian:
Email Address: ________________________________________________________________________________
FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the
veterinarians of Action
Care Mobile Veterinary Clinic, LLC,
and their support staff, to administer such treatment and/or perform such
diagnostic or surgical procedures as deemed necessary.
is understood that an estimate of charges will be given for services. No
guarantee or assurance can be made as to the results that may be obtained.
I understand that a deposit of at least 50% is required before services are
performed and all final charges must be paid at time of discharge. I assume full financial responsibility for
all charges incurred by my pet. I realize that these charges may exceed a given
estimate if complications arise. I understand that I will be contacted prior to
treatment, if possible, should complications occur.
billing or credit is available through our service. Please indicate your choice of payment:
[ ] Cash [ ] MC/Visa [
] Other: ________________