Client Information Form

We are pleased to welcome your pet(s) to our practice. Please take a few minutes to fill this form. If you have any questions, we're happy to help.

Name*

First NameLast Name

Today's Date*

Date

Spouse or Co-Owners Name

Street Address*

City*

State*

Zip*

County*

If you are unsure, you may answer "unknown"

Mailing Address (if different from above)

City

State

Zip

Primary Phone Number*

Can we send text messages to this number?*

YesNo

Secondary Phone Number

We will always try your primary number first.

Can we send text messages to the secondary number?

YesNo

Work Number

Please enter a valid phone number.

E Mail Address*

example@example.com

For non-emergency communication, I prefer to be contacted by:*

Text MessageEmailOther

In an the event of an emergency, please call*

If you personally experience an emergency (e.g. fainting) while at our clinic, whom should we call?

Emergency Contact Phone Number*

Pet's Name*

Estimated Date/Year of Birth*

Species:*

CatDogOther

Breed*

Examples: Beagle mix or Domestic Shorthair

Sex*

MaleFemale

Spayed or Neutered?*

Spayed FemaleNeutered MaleIntact (NOT spayed or neutered)

Colors/Markings*

Examples: Tri-color or Black with white spots

Is this pet micro-chipped?*

YesNoI'm not sure.

Any Allergies?*

Example: Lyme vaccine or penicillin

Previous Veterinarian(s)*

Please list previous all veterinary clinics. We will call them for records. If you have records from a mobile clinic, breeder, or rescue; we ask you to email a copy or photo of the records prior to your pet's first appointment.

Do you have another pet you would like to add to your account here?*

YesNo

Photography Release

Sometimes we use photos of our patients. We only use the pet's name, never the owner's name without prior permission. Unless indicated otherwise, I hereby give permission for photos of my pet (s) to be taken and used for publication, education purposes, and/or promotion of Lee's Hill Pet Hospital.

Regarding the use of my pet's picture:*

I authorize the use of my pet's pictureI DO NOT authorize the use of my pet's picture

Authorization For Treatment and Credit Agreement

I hereby authorize the Veterinarian(s) to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges are due at the time services are rendered. If a balance is unpaid after services are rendered, I agree to pay a service charge of five percent (1.5%) per month computed on the unpaid balance until the account is paid in full. I also agree to pay all attorney fees, collection agency fees, court fees and all other costs incurred in our collection process on all unpaid balances I may owe.

I understand that if anyone else other than myself brings in my pet or picks my pet up, then they need to be responsible to pay the bill in full when the services are rendered or prior to the release of the animal.

Signature of Owner or Legal Agent*

Pet's Name

Estimated Date/Year of Birth

Species:

CatDogOther

Breed

Sex

MaleFemale

Spayed or Neutered?

Spayed FemaleNeutered MaleIntact (NOT spayed or neutered)

Colors/Markings

Is this pet micro-chipped?

YesNoI'm not sure.

Any Allergies?

Example: Lyme vaccine or penicillin

Previous Veterinarian(s)

Please list previous all veterinary clinics. We will call them for records. If you have records from a mobile clinic, breeder, or rescue; we ask you to email a copy or photo of the records prior to your pet's first appointment.

Do you have another pet you would like to add to your account here?

YesNo

Pet's Name

Estimated Date/Year of Birth

Species:

CatDogOther

Breed

Sex

MaleFemale

Spayed or Neutered?

Spayed FemaleNeutered MaleIntact (NOT spayed or neutered)

Colors/Markings

Is this pet micro-chipped?

YesNoI'm not sure.

Any Allergies?

Example: Lyme vaccine or penicillin

Previous Veterinarian(s)

Please list previous all veterinary clinics. We will call them for records. If you have records from a mobile clinic, breeder, or rescue; we ask you to email a copy or photo of the records prior to your pet's first appointment.

Do you have another pet you would like to add to your account here?

YesNo

Pet's Name

Estimated Date/Year of Birth

Species:

CatDogOther

Breed

Sex

MaleFemale

Spayed or Neutered?

Spayed FemaleNeutered MaleIntact (NOT spayed or neutered)

Colors/Markings

Is this pet micro-chipped?

YesNoI'm not sure.

Any Allergies?

Example: Lyme vaccine or penicillin

Previous Veterinarian(s)

Please list previous all veterinary clinics. We will call them for records. If you have records from a mobile clinic, breeder, or rescue; we ask you to email a copy or photo of the records prior to your pet's first appointment.

Do you have another pet you would like to add to your account here?

YesNo

Pet's Name

Estimated Date/Year of Birth

Species:

CatDogOther

Breed

Sex

MaleFemale

Spayed or Neutered?

Spayed FemaleNeutered MaleIntact (NOT spayed or neutered)

Colors/Markings

Is this pet micro-chipped?

YesNoI'm not sure.

Any Allergies?

Example: Lyme vaccine or penicillin

Previous Veterinarian(s)

Please list previous all veterinary clinics. We will call them for records. If you have records from a mobile clinic, breeder, or rescue; we ask you to email a copy or photo of the records prior to your pet's first appointment.

Do you have another pet you would like to add to your account here?

YesNo

List other pets' names, ages, species, breed, sex, color, and any allergies.

Example: Barney, 10 years, Canine, Beagle, Neutered Male, Tri-Color, No allergies

Email

example@example.com