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Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Pet Information

Referral Information

Statement Of Ownership

By checking below you certify that you are the owner and / or agent of the above animal and have the authorization to consent to treatment if and when it is needed.

Financial Statement

Payment is due in full at time of service. An estimate will be presented to you for the cost of services other than routine visits (well pet exams and vaccines). Payment plans are to be determined prior to treatment and on an individual basis, the terms of which will be set by Clearlake Veterinary Clinic. All unpaid balances are subject to a monthly billing fee plus 1.5% (18% APR) interest rate. The doctor / patient / client relationship will be terminated if there is default on payment.

Sign at check in with reception: _______________________________________________