541-672-1621
parkwayreception@gmail.com
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Please fill out this form as completely and accurately as possible so we can get to know you
and your pet(s) before your visit.
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Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New York
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Ohio
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
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Tennessee
Texas
Utah
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Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
*
Work Phone
Cell
Layout
Drivers License
State
Layout
Employer
Phone
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Emergency Contact
(Not the same as above)
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Relationship
Professional fees are due when services are rendered. We accept cash, checks, VISA, MasterCard, Discover, and Care Credit. I understand that I assume responsibility for all charges, past and present, incurred in the care of my animal(s), and they will be paid at the time of release. I also understand that a deposit may be required for surgical treatment or hospitalization. I realize that if my account is not paid in full, it will be charged interest at the rate of 18% annually ($0.50 min). Accounts sent to collections will be subject to a minimum fee of 30.00. There is a return check fee of $35.
*
I have read and accept
Signature
*
Clear Signature
Date
*
Pet's Name
*
Species (dog, cat, etc.)
*
Age/Date of Birth
*
Breed
*
Policies
Please read through our current hospital policies and initial
Photograph
*
I agree Parkway Animal Hospital may take pictures and videos of my pet for continuing education, medical publications, promotion, social media, etc. These images will have no identifying information about me or my family associated with them. They may contain my pet's name. I will claim no ownership of or authority over said images.
No Shows & Late Cancellation Fees
*
I understand that Parkway Animal hospital requires a 24-hour advanced notice for changes in your scheduled exam. With the 1st missed appointment, our staff will call to ensure the well-being of you and your pet, in addition to rescheduling your exam. Additional missed exams and late cancellations may result in a $50.00 fee or upfront payment of exam fees.
Emergency and After Hours
*
Parkway Animal Hospital provides consultation and or care for our current clients. If we have not seen the patient or your family has not visited the clinic within the last 3 years, an emergency client reinstatement fee will apply.
Mutual Respect
*
Our team is committed to treating all clients with dignity and respect. We do ask that you give our team the same consideration. For the safety and well-being of the patients in our care, other clients, and our team, we will not tolerate cursing, yelling and/or any attack on our staff. Failure to act in a calm and respectful manner may result in the termination of your relationship with Parkway Animal Hospital.
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