Client Information Form

Client Information Form



Please list authorized person(s) to make decisions regarding my pet(s):

Pet Information

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Is your pet Neutered or Spayed?


We will gladly prepare a written estimate of service fees if you desire. All professional fees are due at the time services are rendered. In cases of extensive medical or surgical procedures where full payment may be difficult at discharge, we accept major credit cards or can establish a payment arrangement if approved in advance of treatment. There will be a service charge for any checks returned unpaid.

To prevent the spread of infectious disease to other clients, their pets and our staff, we recommend that all hospitalized patients be current on vaccinations and require that they be vaccinated for rabies and be free from internal and external parasites. The signature below authorizes this level of preventative care and that appropriate charges will be taken care of by you, the signee.

I hereby give my consent for CountrySide Veterinary Service to photograph and/or video my pet(s). I also give consent to copyright, use, publish, exhibit and distribute any photos/video of my pet, as well my pet’s name, in order to advertise, publicize and promote CountrySide Veterinary Service through our website, newsletter, facebook and brochures. I waive the right to approve the final product(s.)

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