Name: Oregon Veterinary Referral Associates
Address: 444 B St, Springfield, OR, 97477, USA

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Date*
Date Format: MM slash DD slash YYYY
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*
Secondary Phone*
Employer*
Email*
Referral Veterinary Practice*
Veterinarian*
Pet Info
Pet's Name*
Species*
- Canine
- Feline
Breed*
Color/Markings*
Sex*
Spayed/Neutered*
- Yes
- No
Age*
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*
Date Format: MM slash DD slash YYYY

Client Information

Pet Info