New Client Form

New Client Form

Companion Animal Clinic
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Secondary Person on Account (if applicable)

First NameLast Name
Occasionally, we post photos of pets onto social media highlighting their good care, excellent at-home treatment, behavior, or funny antics. Only positive things will be posted, never anything negative!

I grant to Companion Animal Clinic, its representatives and employees, the right to take photographs of me and/or any of my pets, and to copyright, use and publish the same in print and/or electronically.

I agree that Companion Animal Clinic may use such photographs of me and/or my pets with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, social media, and other Web content.
*

The above may publish photos of me and/or my pets.The above may NOT publish photos of me and/or my pets.
By signing this document, I hereby authorize the staff of Companion Animal Clinic to examine, prescribe for, treat, or perform surgery on my pets. I also consent to the administration of such anesthetics or sedatives as are necessary in the performance of such.

I agree to pay fees for services rendered at the time the patient is discharged or when service is otherwise terminated.

Any returned checks or unpaid balances are subject to a $25.00 returned check fee, monthly finance charges and/or will be sent to a collection agency.

If I miss or move an appointment without contacting Companion Animal Clinic more than 24 hours in advance, my account will be charged a $50.00 no-show fee.

I agree to abide by Companion Animal Clinic's posted Code of Conduct.

I understand that the staff is not on premises 24 hours a day.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: