Sangaree Animal Hospital at Cane Bay New Client & Social Waiver Form

SAHCB New Client & Social Waiver Form

Thank you for the opportunity to care for your pet. Please help us best meet your needs by completing this form.
Pet Owner Information
Owner's Name*

First NameLast Name
Secondary Owner Name

First NameLast Name
Appointment Date*

MonthDayYear
Date
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #*
Format: (000) 000-0000.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Spouse/Other Contact #
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address*
example@example.com
Secondary Email Address
example@example.com
EmailTextPhone Call
ClientEmployeeOther Hospital/DoctorInternetFacebookYelpPhone BookDrove/Walked ByOther
Who can we thank for the referral?*
Pet Information
Patient's Name*
DogCatOther
Birthdate*

MonthDayYear
Date
Age*
MaleFemale
Breed*
Color/Description*
Pet's Instagram Handle
YesNo
YesNo
If yes, what is their microchip #*
Reason for visit*
List your pet's medical conditions (if any)
YesNoNot Applicable
If yes, what hospital should we contact?*
If you have a copy of your pet(s) records from a previous hospital, please upload them below. (Maximum 4 files, 500kb each)

Cancelof
Signature of Owner*
Today's Date*

MonthDayYear
Date
Testimonial and Photo Release
I hereby give Sangaree Animal Hospital at Cane Bay permission to take photographs and videos of me and my pet for the purpose of posting on Sangaree Animal Hospital at Cane Bay's Facebook, Instagram, Twitter, and clinic website.

I hereby release and discharge Sangaree Animal Hospital at Cane Bay from any and all claims arising out of use of the photos.
Yes - please sign and date belowNo
Name*

First NameLast Name
Signature*
Date of Signature*

MonthDayYear
Date
If unable to place signature above, please enter your initials here to sign.
If under 18, PARENT/GUARDIAN MUST SIGN
Date of Signature of Parent/Guardian

MonthDayYear
Date
Should be Empty:

SAHCB New Client & Social Waiver Form

Pet Owner Information

Pet Information

Testimonial and Photo Release