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Carrboro Plaza Veterinary Clinic

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					                     Carrboro Plaza Veterinary Clinic
                              Sheri Randell, DVM ♦ Mary Snyder, DVM ♦ Jenny Marin, DVM ♦
                                       Anne Gavin, DVM ♦ Patricia Howland, DVM
                                                           104-M Carrboro Plaza
                                                           Carrboro, N.C. 27510
                                                               919-929-0031
                                         CLIENT/PATIENT INFORMATION

                                                                                                        ID:_______
                                                                                                        IE:_______ NCL:_______
                                                                                                        (Office Use Only)

Name_____________________________________________ Home phone_____________________ Work phone____________________

Address____________________________________________City____________________State______Zip___________

Where employed _______________________________________________________________________________

Driver’s license #_____________________________State issued_______

Emergency contact name & # (other than you) ________________________________________________________________

Do you have pet insurance? (circle) Yes / No If yes, company name:____________________________________________

Do you plan to board your pet with us? (circle) Yes / No

        How did you first hear about us?

                 BellSouth Yellow Pages _________________
                 Shop In Carrboro Plaza? _________________                       Radio? ________________________
                 Talking Yellow Pages ___________________                        Other? _________________________
                 Veterinary Referral? _____________________                      Internet? _______________________
                 Friend? _____ Who? _____________________                (We always welcome client referrals from satisfied pets &
                                                                         pet owners!)

         1. Pet Name__________________________________ Species______________________ Breed_______________________

           Sex________ Fixed? Yes / No       Color ______________________________________ Birth-date? __________________

         2. Pet Name__________________________________ Species______________________ Breed_______________________

           Sex________ Fixed? Yes / No       Color ______________________________________ Birth-date? __________________

         3. Pet Name__________________________________ Species______________________ Breed_______________________

           Sex________ Fixed? Yes / No       Color ______________________________________ Birth-date? __________________

         4. Pet Name__________________________________ Species______________________ Breed_______________________

           Sex________ Fixed? Yes / No       Color ______________________________________ Birth-date? __________________


         PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We will
         gladly prepare an estimate if you desire. Please ask the receptionist or doctor for details. Any
         outstanding balances over 30 days will be charged a finance charge of 1.5% per month (18% per
         year).

         I have read and understood the above payment policy. Signature:__________________________________________

				
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