New Client Information Form
Roane Veterinary Hospital
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Number
Please enter a valid phone number.
Email
example@example.com
Pet's Name
Reason for Visit
Previous Veterinarian (for retrieving records)
How did you hear about us
Google
Facebook
Referral
Drive-By
Other
Release of Records Waiver: I would like to authorize the release of my pets’ records to other hospitals, groomers, boarding facilities, and/or adoption agencies
Photo/Social Media Release Waiver: I grant Roane Veterinary Hospital, and its employees, the right to take photographs of me and/or my pet(s), and to copyright, use, and publish the same in print, electronically, and/or post publicly in the clinic. I agree that Roane Veterinary Hospital may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including such purposes as publicity illustration, advertising, and Web content.
I understand and agree that payment is due at time of service
Electronic Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: