Client Information Form
Thank you for giving us the opportunity to care for you pets. To assist us in providing the best care possible, please take a few moments to fill out this form completely.
NAME
*
First Name
Last Name
SPOUSE/OTHER
First Name
Last Name
SS# or DL#/STATE
*
CELL PHONE #
*
Please enter a valid phone number.
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MAILING ADDRESS (IF DIFFERENT THAN PHYSICAL ADDRESS)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMAIL ADDRESS
example@example.com
YOUR EMPLOYER
WORK PHONE
SPOUSE WORK PHONE
PET HEALTH HISTORY
NAME OF PET
*
TYPE OF PET
*
DOG
CAT
HORSE
SEX
*
MALE INTACT
MALE NEUTERED
FEMALE INTACT
FEMALE SPAYED
BREED
*
COLOR
*
DATE OF BIRTH OR AGE
*
VACCINE HISTORY (IF NOT AT THIS CLINIC)
*
REASON FOR VISIT
FOR ADDITIONAL PETS: NAME, SEX, BREED, COLOR, AGE
AUTHORIZATION
Escatawpa Animal Clinic, PLLC Financial Policy
I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS. I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT ANY CHARGES WILL BE PAID AT THE TIME OF RELEASE. I UNDERSTAND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL PROCEDURES AND/OR HOSPITALIZATION. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
SIGNATURE
*
DATE OF SIGNATURE
*
-
Month
-
Day
Year
Date
METHOD OF PAYMENT
AMEX
CARE CREDIT
CASH
DISCOVER
MASTERCARD
VISA
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