Rum River - Client Info and Medical Authorization -

CLIENT AND PATIENT INFORMATION
Owner Name #1

First NameLast Name
Owner Name #2

First NameLast Name
Email
example@example.com
Owner's DOB (for Pet Prescriptions)
Address

Street Address

Street Address Line 2

CityState / 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.

Clear
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Pet's Name
Color
Age
Date of Birth
{petsName} is a

DogCat
Breed
Sex

MaleNeutered MaleFemaleSpayed 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:

BoardingEmergency ClinicsGroomingPet Rescue GroupsPolice DepartmentSecondary Veterinary ClinicRelativesOther
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

Clear
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!
Should be Empty:

CLIENT AND PATIENT INFORMATION