First Name *
Last Name *
Address *
City *
State *
ZipCode *
Home Phone *
Email Address *
Employer *
Spouse/Significant Other
Spouse/Significant Other Phone
How did you hear about us?
If other, where?
If referral, who should we thank?
Payment is expected when services are rendered.
What is your preferred method of payment? *
Why did you decide to visit us?
Who is your current vet?
Are you personally allergic to dogs or cats?
Would you be interested in learning more about holistic therapies offered by Dr. Karen Ellis, such as acupuncture, herbal therapies, massage, stem cell therapy and more? *
Comments about Holistic Servcies
BY SUBMITTING THIS FORM, I AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIME OF DISCHARGE. I ALSO AGREE TO PAY ANY FEES INCURRED FOR COLLECTION OF SAID CHARGE. I UNDERSTAND THAT FEES MAY VARY DEPENDING ON THE NATURE OF MY PETS CASE AND THE REQUIRED CARE AND TREATMENTS. AS A RESULT, ESTIMATED FEES MAY BE RAISED OR LOWERED. I UNDERSTAND THAT BEES FERRY VETERINARY HOSPITAL IS OFFERING A VARIETY OF TREATMENT OPTIONS, INCLUDING HOLISTIC AND ALTERNATIVE OPTIONS. BY AUTHORIZING ANY TREATMENT THROUGH CONSENT AND/OR PURCHASE, I RELEASE BEES FERRY VETERINARY HOSPITAL AND ITS AGENTS FROM ANY LIABILITIES. I UNDERSTAND THAT PICTURES AND VIDEOS OF MY PET MAY BE USED FOR BEES FERRY VETERINARY HOSPITAL RECORDS AND PUBLICITY BUT WILL NEVER BE SOLD, TRADED OR USED FOR OTHER REASONS. *
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