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ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Spouse or Co-Owner First Middle Last Spouse's EmployerCell PhoneHow did you hear about us? (Please check One)FacebookWebsiteLocationYellow PagesGooglePet No.1Pet's Name*Type*DogCatBreed*Sex*Color*Neutered?*YesNoDate Last Vaccination*Last Rabies Vaccination*Pet No.2Pet's NameTypeDogCatBreedSexColorNeutered?YesNoDate Last VaccinationLast Rabies VaccinationI hereby authorize Eastside Animal Hospital, to examine, prescribe for, treat, or perform surgery upon the above-described pet(s). I also consent to the administrations such anesthetics as are necessary. I give my permission for photos and videos taken at Eastside Animal Hospital to be shared on their social media sites. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the clinic or when service is otherwise terminated. I further understand that veterinary service is provided during night time hours as necessary and is the judgment of the veterinarian. Continuous presence of qualified personnel may not be provided at all times.Please select your preferred method of payment:*CashCheckCredit/DebitDigital signature of owner or responsible agent (write full name)*CAPTCHANameThis field is for validation purposes and should be left unchanged.