Mohawk Alley Animal Hospital New Client Intake Form

Name of Primary Owner*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Date of Birth (required to dispense controlled substances)*

mm/dd/yyyy

Co-Owner Name

Co-Owner Phone Number

Co-Owner E-mail Address

Patient Name*

Patient Age or Date of Birth*

Species*

CanineFeline

Breed*

Male or Female?*

MaleFemaleUnsure

Spayed/Neutered?*

YesNoUnsure

Color*

Name and Phone Number of Previous Veterinary Hospital*

So we can call and get your records transferred!

Patient Name

Patient Age or Date of Birth

Species

CanineFeline

Breed

Male or Female?

MaleFemale

Spayed/Neutered?

YesNo

Color

Please name any additional pets here

Name/Age/Species/Breed/Sex/Spayed or Neutered?

May we share pictures or stories about your pet(s) online?*

Yes!No, please don't share information about my pet(s) outside of the clinic

I, First Name Last Name am aware that a $32 cancellation fee will be charged for all appointments that are canceled or rescheduled with less than 4 hours' notice, and a $12 restocking fee will be charged for medications which are requested but not picked up within 7 days.

This is an Agreement between Mohawk Alley Animal Hospital, Inc., a California corporation ("Mohawk Alley")
and First Name* Last Name* (PET OWNER) whose signature appears below (hereinafter called "Owner").

1. By signing this Agreement and leaving your pet (“Pet”) with Mohawk Alley, Owner certifies to the accuracy of all information provided to Mohawk Alley in writing or orally about the Pet. Mohawk Alley reserves the right to deny admittance to the Pet or any pet for any reason at any time.

2. Owner specifically represents that he or she is the owner of the Pet, free and clear of all liens and encumbrances.

3. This Agreement contains the entire agreement between the parties on the subject matter referenced herein. All terms and conditions of this Agreement shall apply to any transactions between Mohawk Alley and Owner and shall be binding on the heirs, administrators, personal representatives and assignees of the Owner and Mohawk Alley.

4. Any disputes between Mohawk Alley and Owner which may arise at any time including any controversy or claim arising out of or relating to this Agreement, or the breach thereof, or as the result of any claim or controversy involving the alleged negligence by any party to this Agreement, shall be settled in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof. The arbitrator(s) shall apply California law to the merits of any dispute or claim, without reference to conflicts of law rules. The parties hereby consent to the personal jurisdiction of the state and federal courts located in California and agree that such courts shall have the sole and exclusive jurisdiction for any action or proceeding arising from or relating to this Agreement or relating to any arbitration in which the parties are participants. THE PARTIES HAVE READ AND UNDERSTAND THIS CLAUSE 4, WHICH DISCUSSES ARBITRATION. THE PARTIES UNDERSTAND THAT BY SIGNING THIS AGREEMENT THAT THEY WILL SUBMIT ANY AND ALL CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH DISPUTES BETWEEN MOHAWK ALLEY AND OWNER WHICH ARISE AT ANY TIME, THIS AGREEMENT OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH OR TERMINATION THEREOF, TO BINDING ARBITRATION, AND THAT THIS ARBITRATION CLAUSE CONSTITUTES A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL AND RELATES TO THE RESOLUTION OF ALL DISPUTES RELATING TO ALL ASPECTS OF THE RELATIONSHIP BETWEEN THE PARTIES

Signature*

Date*

Date

New Client Intake Form

Patient Information

Additional Pets