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Does your Pet has Insurance? Does your Pet has Insurance? Yes No

If "Yes" please, enter Insurance Name

Enter Co-owner's Name (If Applicable)

Emergency Contact Name

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Have your pet been checked for Parasites? Have your pet been checked for Parasites? Yes No

Was your Pet Positive to Parasites or Negative? Was your Pet Positive to Parasites or Negative? Positive Negative

If your pet was positive to parasites did your recheck fecal test? If your pet was positive to parasites did your recheck fecal test? Yes, pet is still positive No, I didn't recheck Yes, pet was negative

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Have more pets? Enter their info Here

Treatment and Communication Consent Treatment and Communication Consent I hereby authorize the veterinarian to examine, prescribe for, or treat my pet(s). I further understand that during the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I assume full responsibility for all charges included in the care of my pet(s). I also understand that the charges are to be paid at the time of service. I understand that if an occasion arises where my pet needs to stay at the clinic for any reason, they must be picked up on the same day by 2:00 P.M. latest, unless told otherwise. I understand that the clinic closes at 3:00 P.M. and accept that there is a late pick-up fee of $50. On occasion, my or my pet's likeness may be captured on video or other media. I hereby authorize Good Care Animal Clinic to use, broadcast, and/or reproduce my and my pet's likeness in video/photograph, print, or other media. I understand that I will not be compensated for any such use. After carefully reading the above, I understand and give Good Care Animal Clinic, his agents, staff and/or representatives Full and complete authority to perform all procedures necessary. Learn more on our Privacy Policy Page and Terms & Conditions By checking this box, you agree to receive text messages from Good Care Animal Clinic related to Customer Care, Marketing and Account Notifications, at the phone number provided above. You may reply STOP to opt-out at any time. Reply HELP for assistance. Messages and data rates may apply. Message frequency will vary.

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