Rum River - Client Info and Medical Authorization -

Owner Name #1

First Name Last Name

Owner Name #2

First Name Last Name

Email

example@example.com

Owner's DOB (for Pet Prescriptions)

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Please provide the email address for invoices to be sent to:

example@example.com

Please initial: By doing so, you’re allowing Rum River Veterinary Clinic to take photographs of your pet(s) to upload to our Facebook Page or Website.

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Emergency Contact Name

Emergency Contact Phone

Please enter a valid phone number.

Pet's Name

Color

Age

Date of Birth

{petsName} is a

Dog Cat

Breed

Sex

Male Neutered Male Female Spayed Female

Please name your last veterinary clinic in case we have to check for old records

Medical Information Release Authorization

I hereby authorize all representatives of Rum River Veterinary Clinic to release any medical history/information which may include vaccine history, behavior, past procedures, medications, etc. of my pet(s) to the following:

Boarding Emergency Clinics Grooming Pet Rescue Groups Police Department Secondary Veterinary Clinic Relatives Other

Please list relatives and phone numbers

If you choose to waive release authorization

I DO NOT wish to have my pet’s medical records release to any of the above options.Is there anyone who you DO NOT authorize to receive information?

Is there anyone who you DO NOT authorize to receive information?

*Please alert our receptionists if you would ever like to discontinue these authorize consents. If you decide to not authorize your consent to any of the aforementioned then we will be calling you for your consent if the situation should arise.

Owner Signature

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Phone Number

Please enter a valid phone number.

In the event of any legal case concerning this pet, Rum River Veterinary Clinic, may need documentation allowing us to give out information to anyone, including you, as the current owner.

*PAYMENT IS EXPECTED AT THE TIME OF SERVICE*

*WE DO NOT ACCEPT CHECKS*

THANK YOU FOR CHOOSING US TO CARE FOR YOUR PET!

CLIENT AND PATIENT INFORMATION