Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Email* Pet InformationName* DOB* Species* Breed* Sex* Male Female Neutered Spayed Coat Color* Pet Insurance Provider* Policy Number* Consent for Medical and Surgical Treatment* I authorize the veterinarian on duty (and assistants) to administer treatment considered therapeutically necessary on the basis of findings during the course of examination. I consent to administration of anesthesia and surgical procedures if indicated. I understand the reasons why the procedures or surgery is necessary and the possible complications. I assume financial responsibility for the charges incurred while my pet is undergoing treatment. I consent to release medical information and authorize direct payment to Bellingham Veterinary by my insurance.