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Client Information Form
Thank you for giving us the opportunity to care for your pet. So that we may become better acquainted, please complete the following:
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1
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Primary Owner's Full Name
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First Name
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3
Primary Owner Address
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Street Address
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Palestine
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4
Primary Owners Additional Information
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Driver's Lic No.
Date of Birth
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5
Primary Owners Contact Numbers and Email
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We love to stay connected!!
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Email
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6
Spouse/Secondary or Co-Owner's Name
First Name
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7
Spouse/Secondary or Co-Owner's Address
Street Address
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City
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Alaska
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California
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Connecticut
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Florida
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Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
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New York
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Ohio
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Texas
Utah
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Washington
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State
Zip Code
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
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Guadeloupe
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Guatemala
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Guinea-Bissau
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India
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Israel
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Liberia
Libya
Liechtenstein
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Mayotte
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Niue
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Northern Mariana
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Palau
Palestine
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
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Senegal
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Sierra Leone
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Slovenia
Solomon Islands
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Somaliland
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South Ossetia
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Spain
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Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Isle of Man
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Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
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US Virgin Islands
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8
Spouse/Secondary or Co-Owner's Contact Numbers and Email
We love to stay connected!!
Home Phone
Cell Phone
Place of Employment
Email
Cell Phone
Home Phone
Work Phone
Email
Cell Phone
Home Phone
Work Phone
Email
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9
All Fees Are Due At The Time Services Are Rendered
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Please indicated choice of payment
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Major Credit Card
Care Credit
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10
Veterinary Vision Center Payment Policy.
*
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Estimates are available for all services. Owners are responsible for any charges incurred by their pet while in the care of the doctors at Veterinary Vision Center and/or University Veterinary Hospital. Charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.25%. Any balance that is left unpaid will be forwarded to Veterinary Vision Center's and/or University Veterinary Hospital collection agency and will incur a delinquent billing service fee of $25 and a possible collection fee for which the owner is liable, in addition to monthly finance charges. We offer estimates for all procedures and reserve the right to require partial payment in advance for the services provided to your pet. Please read all forms and make sure that you understand the forms before signing them. Payment is due at the time of service. Please discuss any financial concerns prior to your pet's care.
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11
How did you become aware of our clinic?
*
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Drove by
Advertisement - Paper/Magazine
Advertisement - Mailer
Friend recommendation
Referred by your primary veterinarian
Previous client...Welcome Back!
VVC Facebook @veterinaryvisioncenter
VVC Instagram @veterinaryvisioncenter
Web Site - www.veterinaryvisioncenter.com
Blogs on our website - www.veterinaryvisioncenter.com
News Clips on Local News Channels
Heard through UVHvets in Shreveport
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12
Personal or Veterinarian Recommendation
Whom may we thank?
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13
Picture permission for team education and VVC social media
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14
Pet Information
*
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There is section on this form is where you can upload any digital records you may have.
Name
Species
Breed
Date of Birth
Color
Sex
Spayed or Neutered?
Pet
Pet
Name
Species
Breed
Date of Birth
Color
Sex
Spayed or Neutered?
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15
Medical Records
If you have any medical records for your pet, please upload them here. You may also bring them to the appointment so we can scan and add to your pets medical records at UVH.
Drag and drop files here
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Max. file size
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What practice can we contact on your behalf for your pets medical history if you do not have them to bring or upload?
Practice name, city and phone number ( if you have it) if not from Shreveport/Bossier area
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Signature of Client
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