Client Information Form - Sommers Veterinary Hospital

9347 S. State Road 15
Silver Lake, IN 46982

Name:(Required)

First Last

Phone Number:(Required)

Email:(Required)

Spouse's Name(Required)

Phone Number:(Required)

Address:(Required)

Street Address City State ZIP Code

Driver's License Number:(Required)

State of Driver's License:(Required)

Pet's name:(Required)

Species:(Required)

DOB/Age:(Required)

Spayed or Neutered?(Required)

Yes

Breed:(Required)

PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED*********
We accept cash, checks, Visa, Mastercard, Discover, American Express and Care Credit.
Kindly call 24 hours in advance to reschedule or cancel your appointment/surgery. If you fail to show up, you will be required to pre-pay the exam fee when scheduling any future appointments. If this occurs with a surgery, you will be required to pay a $100 deposit at the time of scheduling a future procedure. These fees are NOT REFUNDABLE.

Signature(Required)

Date(Required)