Client Information Form 2021

NEW BALTIMORE ANIMAL HOSPITAL

Client Information:
Full Name *

First Name Last Name
Date of Birth (This is a state requirement for the Prescription Monitoring Program.) *

Month Day Year
Date
Spouse/Significant Other Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
County
PRIMARY Phone Number *

Area Code Phone Number
CELL Phone Number *

Area Code Phone Number
OTHER Phone Number *

Area Code Phone Number
E-mail *
Employer *
Work Number

Area Code Phone Number
May we send you reminders via email? *

Yes No
May we send you reminders via text message:

Yes No
May we text you if your pet is here for surgery?

Yes No
What cell phone number should we use?

__________________________
Are you a senior citizen, 65 or older?

Yes No
If you are a senior citizen, are you retired?

Yes No
Are you active duty military?

Yes No

We LOVE social media! Do we have your permission to share your pet(s) image and story on social media, our story, our website, and other forms of related media? Your name and personal information will never be shared.

Yes No
I give permission to release vaccine information to groomers/daycares/kennels, etc. when requested.

Yes No
Local emergency contact (someone who can make treatment decisions for your pet if you cannot be reached; other than listed above): *
Name and Contact Number
How did you hear about us? *
Referral Client Name:
I understand and agree that all services rendered to my pet are charged directly to me and that I am personally responsible for payment. If collection actions are initiated for any past due amounts, I agree to pay 25% collection fees. I understand that a $6.00 per month billing charge will be added to any outstanding balance. In addition, interest at the arate of 24% per annum will be charged on any past due amounts. A $25 charge will be assessed for any returned checks. I also understand that NBAH will endeavor its best effords on my behalf, however; there are no guarantees associated with veterinary care. I further agree that any claim I may have against NBAH shall be limited to the payments I have made for the services rendered.
Signature *

Clear

Disclosure Form

I understand this hospital has continuous medical staffing from 7AM to 7PM Monday through Friday and as needed for animal care on weekends and holidays. Each animal gets the best medical care, as determined by the doctor in charge, to deal with the needs of the patient. Additional medical staffing will be provided for each case on an individual basis.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

NEW BALTIMORE ANIMAL HOSPITAL