CONFIDENTIAL CLIENT INFORMATION

CONFIDENTIAL CLIENT INFORMATION
Client:
Co Owner:
Address:
City
Zip Code
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Phone:
Alternate Phone:
Alternate Phone Type:

Co-OwnerWorkOther
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
Previous Veterinary Hospital:
I do not have a previous veterinary hospital
Sex

MaleFemale
Neutered/Spayed

YesNo
Whom may we thank for the referral to Minnehaha Animal Hospital?:

Saw in neighborhoodWebsite/onlineVeterinarians.comFacebook or MAH AppOther Hospital
If referred by a person, please share here:
If "other hospital", please list name:
Services I would like more information about:

Wellness PlansRewards Program
Does your pet have insurance?

YesNo
If yes, which company?Company
SOCIAL MEDIA RELEASE: By initialing you grant Minnehaha Animal Hospital 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.
Select one of these 3 options regarding social media:
MAH has permission to take and post images of my pet.
Initial if this option.
I agree to having my pets photo taken for their medical record only but I DECLINE allowing images of my pet to be posted or used in print or digital promotion.
Initial if this option
MAH may NOT take pictures of my pet for any purpose.
Initial if this option
Minnehaha Animal Hospital does not bill for services and cannot accept payment plans. We do accept Visa/Mastercard, American Express, Discover, Care Credit, Scratchpay and cash.

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: