Client Update Form
Name
*
Mr.
Mrs.
Miss
Ms.
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Confirmation Email
Please use the same email address listed here with our FunkstownVet App.
Employers Name
Employers Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Are you Elligible for any of the following discounts?
*
Senior Citizen Discount (65 or older)
Military Discount (Active or retired military with ID)
No, I am not elligible at this time
Is there a Co-owner or second authorized individual you would like added to the account?
*
Yes
No
Co-Owner Name
First Name
Last Name
Co-Owner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Co-Owner Employer Name
Co-Owner Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Method of payment (check all that apply):
*
Cash
Visa/Mastercard/Discover/Debit
Check
Care Credit
Have you downloaded our Funkstownvet app and become a member of our loyalty rewards program?
*
Yes, I have downloaded and activated the app
No, I have not downloaded the app
No I am no interested in downloading the app
We love sharing the happy faces of our patients! May we use your pet's photo on our Social media (Facebook/Instagram), website or other media?
*
Yes, you may share my pet’s photo
No, please do not share my pet’s photo
Clients Acknowledgements
*
I certify that the information I have provided is true and complete to the best of my knowledge. I understand that I am financially responsible for all services rendered, and that payment in full is due at the time of service. I acknowledge that I have been informed of the hospital’s policies regarding, payment, and communication. If my account becomes delinquent, I agree to be responsible for all costs of collection, including collection agency fees, attorney’s fees, and court costs. I agree to abide by these policies as a client of Animal Health Clinic of Funkstown.
Submit
Should be Empty: