Client Information Form 2021

NEW BALTIMORE ANIMAL HOSPITAL

Client Information:
Full Name*

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

MonthDayYear
Date
Spouse/Significant Other Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County
PRIMARY Phone Number*

Area CodePhone Number
CELL Phone Number*

Area CodePhone Number
SPOUSE Phone Number

Area CodePhone Number
E-mail*
Employer*
Work Number

Area CodePhone Number
May we send you reminders via email?*

YesNo
May we send you reminders via text message:

YesNo
May we text you if your pet is here for surgery?

YesNo
Are you a senior citizen, 65 or older?

YesNo
If you are a senior citizen, are you retired?

YesNo
Are you active duty military?

YesNo

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.

YesNo
I give permission to release vaccine information to groomers/daycares/kennels, etc. when requested.

YesNo
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*

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. Outside of these hours we do not offer continuous staff. 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 can be provided for each case on an individual basis.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

NEW BALTIMORE ANIMAL HOSPITAL