Dermatology Clinic for Animals Las Vegas
Kimberly S. Coyner, DVM   DACVD
So that we may become better acquainted, please complete the following:
Mr. Mrs. Ms. Dr. Owner: Spouse:
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Referring Veterinarian: Hospital:
 
Pet #1
Pet #2
Pet#3
Name of Pet
Dog, Cat, Other
Breed
Sex
Spayed/Neutered
Color
Approximate Date of Birth
Known Drug Allergies
All fees are required to be paid in full upon completion of the visit. For your convenience we accept: VISA, Mastercard, Discover, Care Credit, cash, and checks. Sorry, we do not accept American Express.  
I authorize and direct the veterinarians at the Dermatology Clinic for Animals to diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well being. No warranty or guarantee has been made as to the result or cure. 
In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all cost included in said unpaid balance, including a reasonable collection and/or attorney’s fees. 
Owner:  
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