WELCOME TO COASTAL CAT CLINIC!
Thank you for trusting us with your pet’s health. Please take a moment to tell us about you and your pet.
CLIENT INFORMATION
Owner's Name
*
First and Last
Spouse/Co Owner
First, Last if different from above
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Street Address (if different from above)
Primary Email Address
*
example@example.com
Home Phone #
*
If primary cell is home phone note n/a here
Primary Cell Phone #
Ok to text cell?
Yes
No
Primary Work Phone #
Co Owner Cell Phone #
Co Owner Work Phone #
Emergency Contact
*
Someone not already listed here as an owner
Emergency Contact Phone #
*
How did you hear of us?
*
Google
Facebook
Hospital Website
Yelp
Drive By
Referral - Who may we thank (type in the name below)?
Other
If you were referred by a previous client please note their name here so we can thank them
PATIENT INFORMATION
Pet's Name
*
Sex
*
Female Spayed
Female Un-spayed
Male Neutered
Male Un-neutered
Breed
*
Please note that tabby, calico, torti, etc. are colors. If in doubt put domestic short hair or long hair
Color
*
Approx. date of birth
*
/
Month
/
Day
Year
Date
Past veterinarian(s) where past records may be requested?
*
If your pet has not been seen anywhere note none
Was your pet treated for any illness in the past year?
*
No
Yes Please explain problem(s), medication details if known below
If you answered yes above please explain here
Is your pet currently on any medications?
*
No
Yes (Please list below)
If you answered yes above please explain here
Does your pet have any drug sensitivities or reactions?
*
No
Yes (Please list below)
Unknown
If you answered yes above please explain here
Do you authorize Coastal Cat Clinic to use your pet's likeness for marketing purposes, including but not limited to use on CCC's website, Facebook page, or Instagram?
*
Type yes or no
PUBLIC HEALTH Please check the boxes that apply as they could influence course of treatment or preventative recommendations.
Children in household
Person in home is immunosuppressed (Chemotherapy, Transplant, HIV)
Pregnancy in household (a fetus’s immune system is not fully developed)
Pet used for therapy taken to nursing homes etc or service pet
FINANCIAL INFORMATION
I hereby authorize Coastal Cat Clinic and its veterinarians to examine, prescribe for, and treat the above described pet. I release Coastal Cat Clinic and its veterinarians from any liability related to any such care.
*
Please initial
I assume full responsibility for all charges incurred and I understand that a deposit may be required for hospitalization and/or treatment. I understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED and agree to pay for services.
*
Please initial
I understand that there is a minimum $25.00 service charge for all returned checks. Any unpaid accounts more than 30 days past due will be sent to a collection agency.
*
Please initial
Signature of Owner or Financially Responsible Party
Signature (Must be 18 years or older)
*
Today's date
*
/
Month
/
Day
Year
Date
We accept: Cash &
Ch
eck / Debit Card / AMEX & Di
scover / Visa & MasterCard / CareCredit
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