UVH Client Information Form

1
Date* This field is required.
Date
Year
Month
Day
2
Primary Owner's Full Name* This field is required.The person listed below will be the primary point of contact for your account.
Mr.
Mrs.
Ms.
Dr.
Mx.
Prefix
First Name
Last Name
3
Primary Owner's Address* This field is required.
Street Address
Apartment Number
City
Please Select
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
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Owner's Contact Numbers and EmailsPlease enter the contact information for the person who is the primary point of contact for your account. You will be able to add a secondary contact on a following page.
Primary Phone Number
Please Select
Please Select
Cell Phone
Home Phone
Work Phone
What is this number?
Primary Email
Secondary Phone Number
Please Select
Please Select
Cell Phone
Home Phone
Work Phone
What is this number?
Please Select
Please Select
Cell Phone
Home Phone
Work Phone
Email
How would you like to receive communications from the Doctors and other staff members? Such as updates on your pet
5
Primary Owners Additional InformationThis information is part of our financial policy. It is never shared and stored with encryption. Your Social is only required if paying via check.
Driver's Lic No. - Required
Driver's License State
Driver's License Expiration Date
SSN - this is required IF paying with checks.
Date of Birth
Place Of Employement
6
All clients are automatically enrolled to receive updates from UVH!These updates are infrequent but contain valuable information.
Opt-out from UVH updates
7
Pet Information* This field is required.Please tell us about your pet!
Name
What practice can we contact on your behalf for your pets medical history if you do not have them?
Please Select
Please Select
Yes
No
Is your pet insured?
Please Select
Please Select
Yes
No
Picture Permission for team education and UVH social media?
8
How did you become aware of our clinic?
Drove by
Advertisement - Paper/Magazine
Friend recommendation
Referred by your primary veterinarian
Previous client...Welcome Back!
UVHvets Facebook
UVHvets Instagram
UVHvets YouTube Channel
Web Site - www.uvhvets.com
Blogs on our website - www.uvhvets.com
News Clips on Local News Channels
9
University Veterinary Hospital Payment Policy.* This field is required.Owners are responsible for any charges incurred by their pet while in the care of the doctors at University Veterinary Hospital and charges are due and payable at the time of service. Any balance that is left unpaid will be forwarded to University Veterinary Hospital's collection agency and will incur a delinquent billing service fee of $40 and a possible collection fee for which the owner is liable, in addition to monthly finance charges. University Veterinary Hospital does have a $40 NSF service fee for all returned checks. Clients that have a returned check will lose check-writing privileges. We offer estimates for all procedures and reserve the right to require payment in advance for the services provided to your pet. Please read all forms and make sure that you understand the forms before signing them. Payment is due at the time of service. Please discuss any financial concerns prior to your pet's care.
10
Signature of Client* This field is required.
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