Sangaree Animal Hospital New Client Form

New Client Form
Client Information
Name*

First NameLast Name
Appointment Date*

MonthDayYear
Date
Birthdate

MonthDayYear
Date
Primary Email*
example@example.com
Secondary Email
example@example.com
Employer Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home/Main Phone #*
Please enter a valid phone number.
Cell Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Spouse/Co-Owner Information
Name

First NameLast Name
Email
example@example.com
Employer Name
Secondary Spouse Or Other
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Sangaree Animal Hospital provides all clients with online Pet Portal account access. Through the Pet Portal you can access your pet’s medical information, order product(s), and more. We must collect at least one e-mail address in order to provide access to the Pet Portal. We also periodically send informative e-newsletters using this information. Your contact information will never be sold to a third-party and is used exclusively by Sangaree Animal Hospital. If you have any questions regarding these policies, please feel free to ask a receptionist.
Pet Information
How Many Pets Do You Have?
Pet Information - Pet #1
Pet #1 Name*
Birthdate*

MonthDayYear
Date
DogCatOther
MaleFemale
YesNo
Breed
Color
YesNo
Microchip Number (if applicable)
Does your pet have any special needs? If so, please elaborate here:
Pet Information - Pet #2
Pet #2 Name*
Birthdate*

MonthDayYear
Date
DogCatOther
MaleFemale
YesNo
Breed
Color
YesNo
Microchip Number (if applicable)
Does your pet have any special needs? If so, please elaborate here:
Pet Information - Pet #3
Pet #3 Name*
Birthdate*

MonthDayYear
Date
DogCatOther
MaleFemale
YesNo
Breed
Color
YesNo
Microchip Number (if applicable)
Does your pet have any special needs? If so, please elaborate here:
Pet Information - Pet #4
Pet #4 Name*
Birthdate*

MonthDayYear
Date
DogCatOther
MaleFemale
YesNo
Breed
Color
YesNo
Microchip Number (if applicable)
Does your pet have any special needs? If so, please elaborate here:
Pet Information - Pet #5
Pet #5 Name*
Birthdate*

MonthDayYear
Date
DogCatOther
MaleFemale
YesNo
Breed
Color
YesNo
Microchip Number (if applicable)
Does your pet have any special needs? If so, please elaborate here:
Veterinary Care Information
Where & when was your pet(s) last vaccinated?
YesNoNot Applicable
If yes, from where?*
Phone #
YesNo
Referral Information
Drove ByFacebook/Social MediaGoogleYelpWelcome KitWord of MouthPet Shop/Groomer/BreederSPCA/Animal ShelterOther Hospital/DoctorOther
Which Pet Shop/Groomer/Breeder?
Which SPCA/Animal Shelter?
Which other Hospital/Doctor?
Testimonial & Photo Release
I hereby grant Sangaree Animal Hospital permission to use my testimonial or likeness in a photograph, video, or other digital media (“Photo”) in any and all of its publications, including web-based publications, without payment or other consideration, for purposes of advertising the hospital staff or services.

I understand and agree that all Photos will become the property of Sangaree Animal Hospital, and will not be returned.

I hereby irrevocably authorize the Sangaree Animal Hospital to edit, alter, copy, exhibit, publish, or distribute any testimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonial or likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial or Photo.

I hereby hold harmless, release, and forever discharge Sangaree Animal Hospital from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. I ACCEPT:
Yes - if yes, please sign belowNo
Signature for Testimonial & Photo Release*
Date*

MonthDayYear
Date
New Client Signature
I hereby agree that all of the above information is correct to the best of my knowledge, and I assume responsibility for the animal(s) listed.*
Date*

MonthDayYear
Date
Should be Empty:

New Client Form

Client Information

Spouse/Co-Owner Information

Secondary Spouse Or Other

Pet Information

Pet Information - Pet #1

Pet Information - Pet #2

Pet Information - Pet #3

Pet Information - Pet #4

Pet Information - Pet #5

Veterinary Care Information

Referral Information

Testimonial & Photo Release

New Client Signature