New Client Form

El Camino Veterinary Hospital Client Form
Owner's Name *

First NameLast Name
Co-Owner's Name

First NameLast Name
Client ID (Not required)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone *
If you do not have a home phone, please provide your cell number.Format: (000) 000-0000.
Owner's Cell Phone *
Please enter a valid phone number.Format: (000) 000-0000.
Co-Owner's Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email *
example@example.com
Co-Owner's Email
example@example.com
Controlled Medication Policy

In compliance with state and federal regulations, El Camino Veterinary Hospital is required to collect your date of birth and driver's license information in order to prescribe or dispense controlled medications for your pet. This information is kept confidential and used solely for verification and reporting purposes.
Owner's Date of Birth *

MonthDayYear
Date
Owner's Driver's License Number*
Owner's Driver's License Expiration Date *

MonthDayYear
Date
Owner's Driver's License Issuer (State)*
May we request records from your pet's previous veterinarian?*

NoYes (please provide office name below)
Would you like your pet's reminders sent to you via email/text?*

YesNo
Permission to Use Photographs
I grant El Camino Veterinary Hospital, its representatives, and employees the right to take photographs of my pet(s). I authorize El Camino Veterinary Hospital, its assignees, and transferees to copyright, use and publish the same in print and/or electronically. I agree that El Camino Veterinary Hospital may use such photographs of my pet(s) for Web content, such as social media, without expecting compensation or any other consideration.*

YesNo
WE ACCEPT THE FOLLOWING METHODS OF PAYMENT:
- VISA, MATERCARD, DISCOVER, AMERICAN EXPRESS, DEBIT
- CASH
- CARE CREDIT
- CHECK
BY SIGNING BELOW, I UNDERSTAND THAT PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. ON YOUR REQUEST, WE WILL PROVIDE YOU WITH A WRITTEN ESTIMATE FOR ANY CASE, HOSPITAL TREATMENT, EMERGENCY CARE, SURGERY, OR HOSPITALIZATION. A DEPOSIT PRIOR TO TREATMENT MAY BE REQUIRED DEPENDING ON THE AMOUNT OF THE ESTIMATE. RETURNED CHECKS WILL ACCRUE A SERVICE FEE OF $25.00. I HAVE READ AND UNDERSTAND THE CONDITIONS, AND AGREE TO HONOR SAID AGREEMENT.
Owner's Signature*
Should be Empty:

El Camino Veterinary Hospital Client Form

Controlled Medication Policy

Permission to Use Photographs