Client Update Form
Main Contact Name
*
First Name
Last Name
Your Date of Birth
*
Email
*
example@example.com
First Number to Call
*
Please enter a valid phone number.
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.
This is a
Cell
Home
Work
Second Number to Call
Please enter a valid phone number.
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.
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:
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: