MAH ANIMAL HOSPITAL Annual Client Information Form

MINNEHAHA ANIMAL HOSPITAL ANNUAL CLIENT UPDATE
Client*
Co Owner
Address:*
City
Zip Code
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Phone 1*
This phone is a*

CellLandline
Phone 2
This phone is a

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

TextEmailCall
Emergency Contact
Phone
Relationship To Emergency Contact
SOCIAL MEDIA RELEASE: By initialing you grant Minnehaha Animal Hospital permission to take photographs of myself and/or my pet, and to publish those photographs for any lawful purposes but not limited to, their website, social media accounts and promotional materials, either digital or in print, in perpetuity.

MAH has permission to take and post images of my petI agree to having my pets photo taken for their medical record only but I DECLINE allowing images of myself or my pet to be posted or used for digital promotion.MAH may NOT take pictures of me or my pet for any purpose
Please initial: MAH has permission to take and post images of my pet

Clear
Please initial: I agree to having my pets photo taken for their medical record only but I DECLINE allowing images of myself or my pet to be posted or used for digital promotion.

Clear
Please initial: MAH may NOT take pictures of me or my pet for any purpose

Clear
Minnehaha Animal Hospital does not bill for services and cannot accept payment plans. We do accept Visa/Mastercard, American Express, Discover, Care Credit, Scratchpay, 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*

Clear
Date

MonthDayYear
Date
Should be Empty:

MINNEHAHA ANIMAL HOSPITAL ANNUAL CLIENT UPDATE