ANNUAL CLIENT INFORMATION UPDATE

ANNUAL CLIENT INFORMATION UPDATE
Please review the information we have on record for your family and make any necessary corrections.
Client*
Co Owner
Address*
City*
Zip Code*
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Phones*
This phone is a

CellLandline
Phones
This phone is a

CellLandline
Email*
example@example.com
Preferred Contact Method*

TextEmailCall
Emergency Contact
Phone
Relationship of Emergency Contact
SOCIAL MEDIA RELEASE: By initialing you agree to allow Pet Doctors Animal Clinic to use images of your pet on our social media. No identifying information will be posted except the pet's name. Medical information will NOT be posted without a separate authorization from you.

Pet Doctors has permission to take and post images of my petPet Doctors may NOT take photos of my pet.
Please initial - Pet Doctors has permission to take and post images of my pet.

Clear
Please initial - Pet Doctors may NOT take photos of my pet

Clear
Pet Doctors does not bill for services and cannot accept payment plans. We do accept Visa/Mastercard, American Express, Discover, Care Credit, checks and cash. Professional fees must be paid at the time of each visit.

I am at least 18 years of age and I understand that I am financially responsible for all charges today. In the event of a default payment, I agree to pay collections costs and reasonable attorney fees totalling up to 40% of the default amount and any future outstanding amounts.
Signature*

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Date

MonthDayYear
Date
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