PetHealth UrgentCare New Client Form

New Client Form

The staff of PetHealth UrgentCare - Cornelius welcomes you and your pet!
CLIENT INFORMATION
Name*

First NameLast Name
Mr./Mrs./Ms./Dr./Etc.*
Address*

Street Address

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Spouse/Other Name
Spouse/Other Phone
Please enter a valid phone number.
Are you 18 years of age or older?*

YesNo
How did you hear about us?*
If you were referred, please let us know who we should thank!
Email*
example@example.com
Occupation*
Employer*
Alternate emergency contact
Alternate emergency contact phone number
Please enter a valid phone number.
PetHealth Location:*
Would you like us to send medical records to your family veterinarian?*

YesNo
Please provide your pets current veterinary practice: *
PET INFORMATION

	Pet 1	Pet 2	Pet 3
Name
Breed
Color
DOB/Age
Sex (M/F)
Spayed/Neutered (Yes or No)

PAYMENT POLICY, PERMISSIONS & RELEASE OF LIABILITY
Payment is due in full at the time of services rendered.
We accept cash, all major credit cards, Care Credit and Scratchpay. A $30 service charge will be applied to any returned payment.
I hereby grant PetHealth UrgentCare, its representatives and employees, the right to take photographs/video of myself and/or my pet(s) for such purposes as publicity, illustration, or advertising in print and/or electronically.*
Please initial that you have read and understand the above paragraph. If you wish to decline, please indicate "DECLINE"
I hereby grant PetHealth UrgentCare, its representatives and employees, permission to share my pet’s full medical records with any and all animal boarding, grooming, and/or medical facilities.*
Please initial that you have read and understand the above paragraph. If you wish to decline, please indicate "DECLINE"
Please list the names of any individuals that you would like to grant permission in your absence to make medical and financial decisions(including your spouse) regarding the pets listed on this form:
By signing below, I am authorizing the veterinarians and staff of PetHealth UrgentCare to examine, prescribe for and treat the above described pets. I am 18 years of age or older. I assume responsibility for all charges incurred in the care of the described pets. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Client Form

CLIENT INFORMATION

PET INFORMATION

PAYMENT POLICY, PERMISSIONS & RELEASE OF LIABILITY