Welcome to Wynne Veterinary Clinic. As a new client we would like to get to know you and your pet. Please fill in the information, for our records, sign and return it to the receptionist.
Our goal is to make your pets visit as pleasant as possible. If you have any questions, problems or suggestions concerning your treatment or our policies please do not hesitate to ask our staff
Owner Information | Patient Information |
| Last Name________________ | Pet's Name________________ |
| First Name________________ | Age/Hatch Date________________ |
| Spouse________________ | Sex____ Breed __________ |
| Address________________ | Micro-chip#________________ |
| City_________State_____Zip_____ | Previous Veterinarian________________ |
| Home phone________________ | May we obtain your pet's previous records? ___Y ___N |
| Second phone________________ | What do you feed your bird________________ |
| Drivers License #________________ | Do you use any dietary supplements?________________ |
| Social Security #________________ | Cage Size________ Out of Cage Time________ |
| Employer________________ | UV Light____Y ____N Out of Cage Time______ |
| Address________________ | Other reptiles/pets________________ |
| Employer Phone________________ | Eating Normally?_____Y _____N |
| How Will you be paying today? Cash______ Check______ Credit Card______ | Droppings Normal? ___Y ___N |
We only provide quality care to our patients. Quite often, a visit to the vet can be stressful to your pet. Dr. Wynne and her agents, servants and or representatives are released from any liability arising from the visit or treatment.
I acknowledge that I am financially responsible for all charges. To do this we require payment at the time of services. If it becomes necessary to initiate any action to collect any unpaid balances and late payment charges due on your account, you agree to pay the reasonable costs of collection including necessary attorney fees and court costs