Bordetella

Corona

Deworming

DHLP-Parvo

Heartworm Test

Lyme

Heartworm Preventive

Rabies

Flea Preventive

Any previous medicine?

Any previous surgery?

Name of surgery

Any known allergy ?

Name allergic to

Previous Veterinarian

Vet’s Phone #:

Authorization
I, the undersigned, do hereby certified that I am the owner or dull authorized agent for the owner of animal described as above. I do hereby consent and authorize the Gateway Animal Hospital and its staff to obtain medical record from previous Animal Hospital Veterinarian if necessary. I do hereby authorize the veterinarian to examine, test, treat & prescribe for the pet as above. I assume full financial responsibility for all the charges incurred in the care for this pet. I also agree to pay all such charges when service (s) or treatment is rendered.

Pet Owner or Authorized Agent :                                                             Date:........................