Encino Park Vet - New Client Information Form

Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer's Name & Address
Spouse / Other Name

First NameLast Name
Spouse / Other Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse / Other Employer Name & Phone
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name of Previous / Current Veterinarian
How did you hear about us?
Do you have Pet Health Insurance?
We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered.
To help prevent the spread of infectious diseases, ALL hospitalized animals must be current on all vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be updated at the time of your appointment if it is not current.
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) I present for care. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I understand that a service fee of $50.00 will be assessed for each non-sufficient funds check and/or certified letter that must be sent. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to begin Abandoned Animal Proceedings as outlined by State Law.
Sending Name
Sending Email
Please verify that you are human
Should be Empty:

We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered.

To help prevent the spread of infectious diseases, ALL hospitalized animals must be current on all vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be updated at the time of your appointment if it is not current.