Client Update Form
Main Contact Name (Please only add one name here)
*
First Name
Last Name
Your Date of Birth
*
Email
*
example@example.com
First Number to Call
*
Please enter a valid phone number.
Format: (000) 000-0000.
This is a
*
Cell
Home
Work
Second Number to Call
This is a
Cell
Home
Work
Would you like to receive text alerts for things such as appointment reminders, preventative reminders, test results
*
Yes
No
Spouse/or Other Owner
First Number to Call
Please enter a valid phone number.
Format: (000) 000-0000.
This is a
Cell
Home
Work
Second Number to Call
Please enter a valid phone number.
Format: (000) 000-0000.
This is a
Cell
Home
Work
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
How did you hear about us?
Google Search
Website
Drive by Clinic
Social Media
Phone Book
Referral from another client
Other
Who can we thank for the referral?
Pet's Name
*
Has this pet been seen before?
*
Yes
No
Approximate Age
*
Other Pets? Please list their names. If no additional pets, please put N/A.
*
Emergency Contact Name (Other than your spouse or yourself)
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
We are in the process of computerizing our files. Are you interested in receiving mass email reminders in lieu of regular mail?
*
Yes
No
I authorize Akin Hills to use my and my pet's picture on the internet, including on Facebook.
*
Yes
No
Please list the number you would like us to text with these notifications:
We have a new medication which contains nuts. For the safety of your family, please indicate the response that best represents your household below:
*
We have one or more people with nut allergies in our home.
We do not have any nut allergies in our home.
THIS DOCUMENT WILL REMAIN IN EFFECT FOR 3 YEARS BUT MUST BE SIGNED YEARLY. A PHOTOCOPY OF THIS AGREEMENT IS TO BE CONSIDERED VALID AS AN ORIGINAL. I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT IN FULL AT TIME OF SERVICE, AND AM RESPONSIBLE FOR ALL FEES, INCLUDING THOSE INCURRED AS A RESULT OF THE COLLECTION PROCESS, IF NECESSARY.
*
I Agree
Signature
*
Submit
Should be Empty: