NEW CLIENT INFORMATION

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse/Other

First NameLast Name

Spouse/Other Phone Number

Area CodePhone Number

How did you hear about us?*

If you were referred, who may we thank?

Pet's Name*

Pet's Date of Birth or Approximate Age*

Species*

DogCatOther

Sex*

Breed*

Color*

Date of most recent vaccines and where were they given?*

Is your pet on any routine medications? If so what?*

Do you grant permission for Hog Mountain Animal Hospital to take photos of my pet(s) and use for any lawful purpose, including, publicity purposes, illustration, advertising, and web/social media content?*

YesNo

Payment Policy

Payment is due at the time of service. We accept cash, checks, care credit, Visa, MasterCard, Discover, American Express, and debit cards. All unpaid balances will incur a 1.5% (18% year) finance charge at the end of each month. All returned checks will incur a $35.00 service charge.

Medical and Surgical Release

I hereby consent and authorize Dr. Martinez, Dr. Britt, or any other doctor employed by Hog Mountain Animal Hospital to receive, prescribe for, and treat my pet/pets.

Hospital Policy

For the safety of your pet and others. In order for your pet to stay in the hospital for any services including surgery, boarding, daycare, grooming, drop offs, etc. We require Rabies, DHPP, and Bordetella vaccines; as well as an annual fecal exam for dogs. We require Rabies and FVRCP for cats. Dogs are required to have the Bordetella (Kennel Cough) vaccine every 6 months.

Parasite Policy: If any fleas, ticks, or other parasites are observed, that pet will be treated for these parasites at the owner's expense.

I hereby agree to the above Payment Policy, Medical and Surgical Release Policy and Hospital Policy. I will not hold Hog Mountain Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. Please select yes to indicate that you understand and agree with the above information.*

YesNo

Signature*

Signing this form means you agree to the above policies