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Client Information

Owner's Name*
Spouse's Name
Mailing Address*
Physical Address
(if different than mailing)
This is for reminder and patient update purposes please fill in
Person(s) Authorized to bring in Pets
How did you hear about us:

Number of pets
( We do not see large animals )
Pet information: Please list pet’s name & description on each pet as below asks.
Spayed or Neutered


I (client/owner) hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical or emergency treatment. Should I leave my pet(s) at any time & be unable to pick them up within a reasonable amount of time as agreed upon, Main Street Veterinary Clinic reserves the right to do as deemed necessary for the well-being of the pet(s) & said client above will still be financially responsible for any balance due. We do NOT offer payment plans at this time. We do offer Care Credit should you request assistance, but still all payments will be due in full upon services rendered. Thank you for your understanding.
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This field is for validation purposes and should be left unchanged.