Client Information Form

Client Information Form
Thank you for giving the Imperial Animal Hospital the opportunity to care for your pet. So that we may become better acquainted or update our files, please complete the following:
Primary Owners Name
Address

Address

Street Address Line 2

CityState / Province

Zip
Email Address
example@example.com
Primary Phone Circle one: Cell or Home
Secondary Phone Circle one: Cell or Home
Driver's License Number
Birthdate

MonthDayYear
Date
Spouse or Joint Owner
Secondary Phone Circle one: Cell or Home
Primary Phone - Circle one: Cell or Home
Name
Breed
Birthdate

MonthDayYear
Date
Name
Breed
Birthdate

MonthDayYear
Date
How did you hear about us? Facebook, Internet, Yellow Pages or other
Did someone refer you to us? Please share their name with us and we will send them $10.00 referral dollars!
In case of a major medical problem, who makes the final decision about treatment?
I authorize the release of vaccination information ONLY to other veterinaries, boarding facilities or grooming shops.
I give Imperial Animal Hospital permission to take photographs and videos of myself and my pet for the purpose of posting on Imperial Animal Hospital Facebook, Twitter and clinic website.
Signature Iauthorize the release of vaccination information ONLY to other veterinarians, boarding facilities or grooming shops.
Signature

Clear
Today's date*

MonthDayYear
Date
Payment is required when services are rendered. We accept all major credit cards, Care Credit and checks with valid Missouri or Illinois State driver's license. It is our policy to provide you with a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization will be provided. A deposit prior to treatment may be required upon scheduling.
To maintain this environment, we have a zero-tolerance policy for any form of verbal or physical aggression, including yelling or using inappropriate language toward our staff. Such incidents may lead to immediate removal from the premises and potential prosecution. We believe that mutual respect is essential for fostering a caring and professional atmosphere. We promise to treat you and your pets with the utmost kindness and understanding, and we kindly ask that you extend the same courtesy to our team.
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