Ericka Gibson

Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.

• Owner Name: Spouse/Other:
• MAILING ADDRESS:
• Physical Address
• City/State/Zip
• Home Phone # Cellular #
• Client E-mail Address
• Employer Name / Phone Number
• EMERGENCY CONTACT NAME/PHONE #
• PAYMENT TERMS
• Payment in full is required at me services are rendered
• We accept cash, VISA, Mastercard, Debit card
• Deposits are REQUIRED for emergency procedures
• We DO NOT bill for our services
• PLEASE READ AND SIGN/DATE BELOW:
• I assume responsibility for all charges incurred in the care of my animal(s)
• I also understand that payment is required at me of service and agree to those terms
• Any remaining balance will accrue monthly interest at 1.5% ($1min) AND $3 monthly billing fee
• I further acknowledge and agree that in the event of non-payment, or returned payment, the balance of my account may be turned over for collec on
• In that event, all collec on and legal fees will be added
• Signature of owner or agent:
• Date:
• Previous Veterinarian ini al ini al ini al ini al
• We will need a copy of your drivers license or state ID for our records
• Next page for animal informa on, Pet #1
• Species: Cat Dog
• Breed: Color:
• Male Neutered male Female Spayed female
• Has this animal ever been pregnant
• NO Yes
• Any known allergies or reac ons to any medica ons or vaccina ons
• If yes, please explain:
• Are you the original owner of this pet?
• If no, how long have you had this pet?
• Name: Species: cat dog
• Breed: Color:
• Female Spayed female Male Neutered male
• Has this animal ever been pregnant
• NO Yes
• Any known allergies or reac ons to any medica ons or vaccina ons
• If yes, please explain:
• Are you the original owner of this pet?
• If no, how long have you had this pet?
• Name:
• Date of Birth/Approx age:
• Any lab work done in the last 12 months
• If yes, what tests?
• Date of Birth/Approx Age:
• Any lab work done in the last 12 months
• If yes, what tests?
• Pet #2, DCLVS Guidelines - 185% of DHHS
• TANF/OHP
• DCLVS Guidelines - 185% of DHHS
• Monthly 2 4 6 8
• Annual 2 4 6 8
• ULVS Staff Signature verifying qualifying paperwork

• Umpqua Low-cost Veterinary Services , Income Qualificaiton Verifica on Sheet 2022 ULVS Income Guidelines Client #___________ Persons in Family Date: ____________ $ 2,595 $ 3,495 $ 4,395 $ 5,296 Feral Cat Program $ 6,196 Oregon Trail Card $ 7,096 SS/SSI/SSD disability $ 7,999 Unemployed $ 8,899 Senior Fixed Income For each addi onal person, add: $700

I enjoy painting, drawing, and listening to music. More importantly to share with my 4 grand daughters.