Coastal Animal Medical Center New Client Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number *

Please enter a valid phone number.

Home Phone Number*

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Spouse/Partner Cell Phone Number

Please enter a valid phone number.

Email*

example@example.com

I am at least 18 years of age and the owner of my pet/s listed below*

YesNo

Name of 1st pet*

Species*

Breed*

Color*

Date of Birth*

Sex*

Spayed FemaleFemaleNeutered MaleMale

Name of 2nd pet

Species

Breed

Color

Date of birth

Sex

Spayed FemaleFemaleNeutered MaleMale

I give permission for the following people to authorize treatment for all of my pets. I understand that I am financially responsible for all charges that are authorized by these people. I also understand that unless I give CAMC written permission for anyone other than me to authorize treatments, CAMC will not perform procedures on my pet(s). I also understand that in order for someone to authorize treatments for my pets, they must be at least 18 years of age.

List name(s) and each item they are allowed to authorize for your pet(s):(Medical Treatments, Surgery/Dental, Euthanasia, Pet Pick up, Food/Med Pickup, All the Above)*

On occasion, CAMC doctors and staff take digital photographs, radiographs and ultrasound images of patients for medical, continuing education, promotional and entertainment purposes. I give permission for my pet's digital images to be shared as follows: (ALL None CAMC Website Referral Doctors Social Media Printed Literature) Please list below all that can be shared.*

I understand that CAMC is not staffed 24 hours per day. I acknowledge that the normal operating hours for CAMC are: Mon - Fri 7:30 am - 7 pm, Sat-Sun 9am - 5 pm (closed some holidays).*

Yes

I understand that if I board my Pet(s) at CAMC, the check out time is 11am. I understand that if I pick up my pet before 11am, I will not be charged for the day of pick up. If I pick up my pet after 11am, I will be charged for the day of pick up.*

Yes

I understand that CAMC offers and sells Premier Pet Club Memberships which give a pet unlimited free medical exams and a 10% discount on products and services for the period of one year from the date of payment of the PPC membership fee. I understand that this plan is for one pet, is non-refundable and is non-transferrable. Iacknowledge that this plan is not insurance, and it does not include preferential appointment scheduling or boarding reservations. CAMC will offer the same boarding reservations and medical appointments for pets regardless of PPCmembership status.*

Yes

I understand that all sales at CAMC, including medications, are final except for Hills and Royal Canin prescription foods. Prescription foods may be returned for CAMC credit, but not for a refund.*

Yes

I understand that payment for all products and services is expected when my pet leaves CAMC (on occasion, CAMC may require a deposit for complicated cases). CAMC accepts cash, debit, credit cards and Care Credit. CAMC does not accept checks for payment.*

Yes

Signature