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  • Pet Information

  • Other pets in the Household

  • NameSpeciesBreedAge 
  • I authorize and direct the veterinarians at 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.
    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.
    In the event any balance due here under 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.
  • Date Format: MM slash DD slash YYYY

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