Patient Check-In - Mechanicsville Animal Hospital

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					                    Mechanicsville Animal Hospital Patient Check-In


Client Name: ____________________________________ Date: _____________
Patient Name(s) ___________________________________________________
                ____________________________________________________
Time of your appointment: _____________ Time of your Arrival____________
Doctor (circle one) Kilgore Beadles Schwartz Not Sure None (Tech or Grooming)


Reason for Today’s Visit: (Check all that apply)
       Annual Vaccines/ Exam
       Puppy/ Kitten Exam &/or Vaccines
       Eye, Ear, or Skin Issues
       Grooming
       Anesthetic Procedure/ Surgery
       Sick
        Symptoms: _______________________________________________
                     _______________________________________________
       Other
        Explain: __________________________________________________
                 __________________________________________________


How will you be paying for your visit today? (Check One)
       Cash
       Check (We use Telecheck and will need a Driver’s License Number)
       Visa, Mastercard, Amex, Discover
       Care Credit


Are you interested in applying for Care Credit?    YES NO


                          ** Ask for a Brochure about PET INSURANCE!!


				
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posted:12/20/2010
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