Emergency Client Form Emergency Client Form Prefix Mr. Mrs. Ms. Dr. Name * Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Parish Home Phone * Cell Phone Employer Work Phone Email * Wife/Husband/Other Phone Emergency Contact * Phone * Photo/Name Release: I agree to allow Avian & Exotic Animal Hospital of Louisiana to use my name, my pets name and photographs of myself and/or my pet for any lawful purpose including publicity, illustration, advertising, web-site, FaceBook, Twitter, Instagram, You Tube and other media I agree The below doctor has informed me of emergency fees in the below amount and provided me with the below estimate amount for services required during this emergency visit. I understand I am responsible for payment in full of these services at time of visit. * I understand Doctor * Dr. Gregory Rich Dr. Leslie Pence Emergency Fees Amount * Estimate amount * ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept: Mastercard / Visa / Discover / American Express / Check / Cash / Care Credit Signature of person responsible for payment * signature keyboard Clear Date * If other than client please print name and relationship to client Captcha Submit If you are human, leave this field blank.
