OCAC Client Information Sheet

Client Information
DateTime
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse/Other

First Name Last Name
Spouse/Other Phone #

Area Code Phone Number
Employer
Work Phone Number

Area Code Phone Number
Other person(s) authorized to order treatment or obtain information (option)
Other person(s) phone #

Area Code Phone Number
Photo Release: Ohio County Animal Clinic, PLLC may use photos of my pet(s) for advertising, social media, and other purposes. I understand that I will not be compensated in any way for allowing usage of my pet(s) image(s).
Type a question *

Yes, my pet(s) image(s) may be used by Ohio County Animal Clinic, PLLC No, I prefer that my pet(s) image(s) not be used by Ohio County Animal Clinic, PLLC
Financial Information
FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

We accept cash, check, Visa, Master Card, Discover, & American Express.

Need financing? We accept Care Credit and ScratchPay. Ask a receptionist for more information.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.
By signing below I acknowledge the information provided is accurate to the best of my knowledge and I fully understand the payment policy.
Please sign in the box (it's hard to see) *

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Client Information