Forms

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Date

Client Information

Name

First Last

Spouse

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone

Cell Phone

Employer

Work Phone

Alternative Phone

Email

Referral Veterinary Practice

Veterinarian

Pet Info

Pet's Name

Species

Canine
Feline

Breed

Color/Markings

Sex

Spayed/Neutered

Yes
No

Age

Date of Birth

I am the owner, or the agent of the owner, of the above-described pet and have the authority to execute this agreement. I authorize Oregon Veterinary Referral Associates (OVRA) to examine and treat the above pet. I accept full financial responsibility for this pet.I understand that payment is due in full at the time of services. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital.We accept Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit. We do not bill for services.I understand that my referring veterinarian will receive a summary of the care and treatment provided by OVRA to ensure that my pet’s care can be continued without interruption. I also understand that OVRA consider the identification of the referring veterinarian by me to be my authorization to release records and information to that veterinarian.Case information and/or photos may be used in teaching, continuing education, veterinary literature, OVRA website (including social media), and for publicity printing purposes. Your confidentiality will be maintained.

Yes
No

Owner/responsible party signature

Date

Address:	444 B Street Springfield, OR 97477
Phone:	541-255-2009

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New Client Form

Client Information

Pet Info

Patient History Form