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Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential.

Pet Information

Canine Medical History (list most recent date)

Feline Medical History (list most recent date)

Referral Information

Thank your for coming to Prior Lake Pet Hospital. Please tell us how you found us by checking any of the following boxes that apply:

If personal recommendation, whom may we thank for refurring you?

Veterinarian Referral

Social Media

Prior Lake Pet Hospital may choose to use photographs of your pet on our website or Facebook page. Would you like to see pictures of your pet on these pages and agree to us using the images? YES NO

Statement Of Ownership

I UNDERSTAND THAT ALL FEES ARE DUE AT THE TIME THE PATIENT IS RELEASED. UPON MY REQUEST, A WRITTEN ESTIMATE OF FESS FOR ANY CASE, HOSPITAL TREATMENT, EMERGENCY CARE, SURGERY, OR HOSPITALIZATION WILL BE PROVIDED. I ALSO UNDERSTAND A DEPOSIT PRIOR TO TREATMENT MAY BE REQUIRED DEPENDING ON THE AMOUNT OF MY ESTIMATE.