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Country Hills Pets  - Client Information Form
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    • United States
    • Afghanistan
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    • American Samoa
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    • Netherlands
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    • Qatar
    • Republic of the Congo
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    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
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    • Samoa
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    • Saudi Arabia
    • Senegal
    • Serbia
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    • Singapore
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    • South Africa
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    • Spain
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    • eSwatini
    • Sweden
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    • 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
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    • Uruguay
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    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
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    • Other
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    • Canine
    • Feline
    • Other
    • Male
    • Female
    • Unknown
    • Yes
    • No
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    • Indoor Only
    • Outdoor Only
    • Both
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    PAYMENT

    We accept the following forms of payment:

     CASH | CHECK | CREDIT/DEBIT CARD | CARE CREDIT     

    As the owner or appointed caregiver of the above listed animal(s), I understand that by signing I agree to pay for the charges incurred by pet’s visit and understand that I must the pay the balance in full upon the discharge of my pet.

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    Please fill out the next portion if your pet is here for a physical therapy consultation.
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    • Yes
    • No
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    I understand that Country Hills Pet Hospital is not my primary doctor. I would like Country Hills Pet Hospital to communicate with my primary doctor on physical therapy performed and recommendations made while at Country Hills Pet Hospital. 
     (Initial)           

    I understand that any services other than physical therapy will be performed by my primary doctor.     (Initial)           

    I grant Country Hills Pet Hospital the right to take photographs of my pet. I authorize Country Hills Pet Hospital to use and publish photographs in print and/or electronically. I consent to allow my pet's picture, case study, etc to be used for purposes such as publicity, blogs, and web content.    (Initial)      

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