CONFIDENTIAL CLIENT INFORMATION

CONFIDENTIAL CLIENT INFORMATION
Client:
Co Owner:
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Phone:
Alternate Phone:
Alternate Phone:

Co-OwnerWork
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:

MonthDayYear
Date
Sex:

MaleFemale
Is your pet neutered or spayed?

yesno
Previous Veterinary Hospital:
We do not have a previous veterinary hospital
Whom may we thank for the referral to Pet Doctors?

Saw in neighborhoodVeterinarians.comFacebook or PD AppWebsite/onlineOther hospital
If "other hospital", please tell us which one
Services I would like more information about:

Wellness PlansRewards Program
Does your pet have insurance?

YesNo
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 petI 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 promotionPet Doctors may NOT take pictures of my pet for any purpose
Please initial
Please initial
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

MonthDayYear
Date
Preferred method of contact*
Should be Empty: