LAKC Heart & Eye
Clinic Registration Form
Sunday, April 27, 2008 Beginning at 10 for
both exams
Sabattus Town Hall, Exit 86/Sabattus
Name:
______________________________________________________________________
Address: ____________________________________________________________________
City: ___________________________________ State:
___________ Zip: ______________
Phone: _________________________________ Email:
______________________________
Number
of Dogs: ___________*Heart Exam $50/dog* _____________ Eye
Exam $30/dog
Dr.
John MacGregor (Cardiologist) Dr. Ruth Marrion
(ophthalmologist)
Go
to www.offa.org and download cardio form. CERF paperwork will be provided
Breed: ________________________________Bring Your
AKC Reg & Micro-chip information.
Indicate
preference for an A.M. or P.M. Appointment?
______________________________
Please come 15
minutes ahead of exam time for eye drops and to fill out CERF forms/dots
q
Check q Money Order Total Heart exams $__________________
Total
CERF exams $__________________
Balance
Due $__________________
(For our Canadian Friends - Postal
Money Orders in US Dollars. These can
be obtained at any Canadian Post Office.)
Please make
checks payable to: LAKC (Lewiston
Auburn Kennel Club)
Mail to: Mary
Dickinson Wood
Cumberland, ME 04021
(207)
829-3700 (home)
Email: k9golden@maine.rr.com
There will be no
refunds for cancellations!
*** If an echocardiogram is necessary,
Dr. MacGregor will do the exam immediately afterwards. An
additional fee of $150.00
will be charged for the use of the ultrasound equipment. Please bring cash or check to be prepared for this contingency.
IF you know your dog needs an echo, you can save $50 by scheduling ahead of exam time for a total of $150 instead of $200.
For our friends from Canada, due to a problem cashing checks drawn from Canadian banks, please bring US dollars
to cover
the cost of any follow-up exams. Thank you.