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<br /> <br />CJ) <br /> <br />~.. <br /> <br />w <br />li <br />o <br />u:: <br />'~ <br /> <br />W LOWER ALFTO BE FILLED IN <br />o I1l\GNllMBl;Il <br /> <br />f3 1- <br />_ IFItSl 11I11815) <br />,~', For L""""""",,,, Usa <br />0:1 ""'noeNo. <br /> <br />I' := <br />,I ,,- <br />0Ih0r <br />1 ChangeD AddD <br />Lc:or.:.____ <br /> <br />I <br />PHONEN &3 -:-d..if 1- 73:Jl <br />(( .1';1",,1!' <br />~I <br />, I <br /> <br />ISi allllll <br />~ess 25d"FtennepJnAve.So. <br />---~-- ~-_:~~~-~~ <br />N ABN <br /> <br />!~mp <br />Teeth/MQuth <br />Ears <br />:Eyes <br />Skin <br />, HearllLung , <br />" Credit Card #: ' <br /> <br />Doctors Comments and Next Visit <br /> <br /> <br />o. <br />o <br />o <br />o <br />,0 <br /> <br />Signature <br /> <br />Exp Date: <br /> <br />How did yc>l!. hear about our clinic tod.ay?' ' , . ' , ' . <br />Pet!'o' 0 I,Ryer-Hand~U~Repeat Service 0 I Word of Mouth d 1 Internet 01 Newspaper-Magazine' 0 <br />I . ," '. <br /> <br />o APPLE VALLEY' 0 HIGHLAND PARK' 0 OAKDALE ~ <br />. 0 BROOKlYN PARK 0 UNWOOD 0 RICHFIELD ' <br />o BURNSVILLE 0 MANKATO 0 ROSEVILLE <br />o COON RAPIDS 0 MAPLE GROVE 0 STILLWATER' <br />o EDEN PRA, IRIE 0 MAPLEWOOD 0 WES~ PAUL <br />o FRIDLEY 0 MINNETONKA : 'I(',i" '. <br /> <br />, · MEDICAL RECORD - SAVE for your permanent file h-~ <br />LABORATORY TESTS. consider your resulls normal unless notifisd, wilhin 5 days <br />Ino~ Any past medical <br />AGE~, ' treatment or illness? yON 0 . Any medication? Y 0 ,N 0 <br /> <br /> , './ <br />1 ' RABIES ( J..-1 T4 <br />2 D!STEMPER-PARVO COMBO I (U/ ~ " <br />3 CORONA d. ( ) <br />4 LYME ( ) , <br />5 BORDETELLA (COUGH VIRUS) (~ 11 "". <br />6 HEARTWORM TEST ( .) <br />7 FECAL (STOOL) TEST ( ) , <br />8 FELINE DIST-RESP COMBO ( ) <br />9 FELINE LEUKEMIA & F.I.V. TEST ( ) <br />10 FELINE LEUKEMIA ( ) <br />11 EXAMINATION ( ) <br />,12 . TREATMENT ( ) <br />13 HEALTH CERTIFICATE (EXAM) ( ) <br />14 DEWORMING , ( j <br />.15 MEDICATION ' ( ) <br />16 HEARTWORM PREVENTION ( ) <br />17 FRONTLINE plus ( ) - <br />18 MICROCHIP (HOME AGAIN) ( ) <br /> SUBTOTAL <br /> I CHECK # (t--lq3[, TAX ' <br />CC I CASH TOTAL '''04. DC <br /> <br /> <br />r' <br /> <br />-:;; _N :.~'.:~:"'~ ::7'~"; .~:.~.r;~~ :)~. ;';;:~~.'~~::~?:~ . ~ <br /> <br /> <br />- ".":" .....:"".:: "l~~"f'.~~"" <br />. ..... :. ~,......: '.:. . <br /> <br />...:-.' <br /> <br />CITY 0' RAMSEY <br />l)OG LICENSE <br /> <br />Tag~o.: 5'0 dl <br />own,mJr~ <br />l-.-J. ' <br /> <br /> <br />Address: 71ttJP <br /> <br />5J}g' )iJtj' <br />at}}...,];]}' <br /> <br />Date: <br />~R~&zff~Phone No.: <br /> <br />,J '7 J <br /> <br />ltJ <br /> <br />Information on Dog: <br />J1 ,), <br />Name: r-'-A UOt{.Ur ' <br />,v ,V I <br />'. Color:1!ll! JJ1} .hr <br /> <br />f <br /> <br />, '. <br /> <br />Breed: JaJ ) tftzf/f.,)t <br /> <br />. , t " <br /> <br />~ ,~r~ <br />Female Spayed <br />License ExpiresS Ji'8' f (/) <br /> <br />Rabies Shot: ' ~) II?? )~ g <br />\_Dl <br />Gff:J ~ <br /> <br />:~:. <br /> <br />7 <br /> <br />