WELCOME TO HOOD RIVER ALPINE VETERINARY HOSPITAL

WELCOME TO HOOD RIVER ALPINE VETERINARY HOSPITAL

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as best you can. If you have any questions we will be happy to assist you. We look forward to working with you in maintaining your pets health.
Client ID #
For Office Use Only
CLIENT INFORMATION
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Spouses Name

First NameLast Name
Spouses Phone Number

Area CodePhone Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Occupation*
Spouse's Employer
Spouse's Occupation
Work Phone*
If necessary, may we contact you at work?*

YesNo
Email:*
example@example.com
Do you have pet insurance?

YesNo
If yes, name?
How did you hear of us?
Name(s) of pet(s)*
PAYMENT IS REQUIRED AT THE TIME SERVICE IS RENDERED OR WHEN THE PATIENT IS RELEASED. WE ACCEPT CASH, CHECK, VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, CARE CREDIT OR SCRATCHPAY.
Signature*

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Date*

MonthDayYear
Date
If under 18 years of age we must have parent or guardian’s authorization.

If you leave your pets in the care of other person we have an alternate form for authorization of care.

Electronic Communication Consent Form
I consent that Alpine Veterinary Hospital can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communications comply with privacy regulations.

Appointment Reminders, Reschedules and Cancellations

I understand that Alpine Veterinary Hospital can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. I also understand that Alpine Veterinary Hospital can employ and use a third-party automated system to reach out me for the purpose of "confirm", "reschedule" or "cancel".

Telemedicine Appointments

For telemedicine, I understand the appointments will be held via electronic environments.

Contact Information Change

I accept that I am responsible of notifying the Company when my contact information change.

Consent Cancellations

I know that I can revoke this consent at any time by contacting the Company.
I CONSENT TO THE USE OF MOBILE PHONE COMMUNICATIONS.*

YesNo
I CONSENT TO THE USE OF TEXTING (MESSAGES) COMMUNICATIONS.*

YesNo
I CONSENT TO RECEIVE ELECTRONIC NOTIFICATIONS FOR CONFIRMING, RESCHEDULING OR CANCELLING MY APPOINTMENTS.*

YesNo
I SIGN THIS CONSENT FORM ON THE BEHALF OF*

MyselfMy FamilyAs a Legal Guardian
Your Name:*
What is your relationship with this person:*
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty: