CONFIDENTIAL CLIENT INFORMATION

Client:

Co Owner:

Address

Street Address Line 2

City

Zip Code

Phone:

Alternate Phone:

Co-Owner Work

HELP US BE GREEN! EMAIL:

example@example.com

(We do not sell our email list. We email reminders, time sensitive alerts and hospital news only)

If we are unable to contact you in case of emergency call:

Phone number

Relationship

Patient:

Breed:

Age/Birthdate:

Date

Sex:

Male Female

Is your pet neutered or spayed?

yes no

Previous Veterinary Hospital:

We do not have a previous veterinary hospital

Whom may we thank for the referral to Pet Doctors?

Saw in neighborhood Veterinarians.com Facebook or PD App Website/online Other hospital

If "other hospital", please tell us which one

Services I would like more information about:

Wellness Plans Rewards Program

Does your pet have insurance?

Yes No

If yes, which company?

SOCIAL MEDIA RELEASE: By initialing you grant Pet Doctors permission to take photographs of your pet and to publish those photographs for any lawful purposes but not limited to our website, social media accounts and promotional materials, either digital or in print.

Pet Doctors has permission to take and post images of my pet I agree to having my pets photo taken for their medical record only but I DECLINE allowing images of y pet to be posted or used in print or digital promotion Pet Doctors may NOT take pictures of my pet for any purpose

Please initial

Pet Doctors Animal Clinic does not bill for services and cannot accept payment plans. We do accept Visa/Mastercard, American Express, Discover, Care Credit, Scratchpay and cash. We do not accept checks. Professional fees must be paid at the time of each visit. We do not accept checks. Professional fees must be paid at the time of each visit.

I understand that I am financially responsible for all charges today. In the event of a default payment, I agree to pay collections costs and reasonable attorney fees totaling up to 40% of the default amount and any other future outstanding amounts.

Signature

Clear

Date

Preferred method of contact *