Client Update Form

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Employer*

Date of Birth

Date

Social Security Number

Email

Must match email on Ridgefield's app

Driver's License Number

Spouse or Secondary owner (will have full access to Record

Spouse's or Seconday's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Spouse's employer

Emergency Contact Name and Phone Number (if different from above)

Person Financially Responsible for Services*

Internet Approval

For educational purposes and so that we may keep you updated, we would like your permission to share your pet's name (first name only), photograph and clinical information (your pet's medical condition, treatment, and prognosis) on Ridgefield's public Facebook, Instagram page and/or business website (ridgefieldanimalhospital.com). Under no circumstance will we divulge any personal information, including your name on these public sites.

Please check one*

I do authorize use of my pet's name (first name only), photograph and clinical information (my pet's medical condition, treatment, and prognosis) on Ridgefield's public Facebook, Instagram page and/or business website (ridgefieldanimalhospital.com).I do not authorize use of my pet's name (first nameonly), photograph and clinical information (my pet's medical condition, treatment, and prognosis) on Ridgefield's public Facebook, Instagram pageand/or business website (ridgefieldanimalhospital.com).

Please check that you have read both*

Payment in full is required at the time of treatment unless prior arrangements have been made. Elective work and medications cannot be financed. For your convenience, we accept cash, checks, Visa, Mastercard, Discover, American Express and Care Credit. If financing occurs, there is a 1.5% interest charged to any unpaid balance older than thirty (30) days.I have read, understand, and fully agree to the above considerations for services performed. I also agree to pay all collection fees (25% of balance), court costs and attorney fees incurred in the collection of any account if it becomes necessary to place my account with a collection agency.

Signature*

Date*

Date

Method of payment*

Credit CardCashCheckCare Credit