Name: Vet Med Animal Hospital
Address: 2901 Kaliste Saloom Road., Lafayette, LA, 70508, US
Telephone: 337-651-2420
Price range: $$

Drop-Off Date*
Date Format: MM slash DD slash YYYY
Owners Name*
Name
Patients Name*
Name
Weight
Phone Number*
Alt. Number
Email*
Why did you bring your Pet in today? Please be detailed
What did you bring with your Pet today?
- Carrier
- Leash
- Collar
- Harness
- Other
Would you like your Pet to have
- Bath
- Nail Trim
- Spa Package
Estimate for services will be give upon drop off
Please indicate your primary choice of payment
What time would you like to pick up Pet?
Note: We apply Flea/Tick Prevention to ANY pet under our care that has flea and ticks. Price estimate range $20-75. Authorization to provide care: I am the owner or authorized agent of the listed above, and therefore authorizes Dr. Scott Tate and staff of Vet Med Animal Hospital to perform the services described above.
Consent*

Estimate for services will be give upon drop off