Fairview Heights Animal Clinic & Animal Hospital of O'Fallon

Owner Name*

First NameLast Name

Co-Owner Name

First NameLast Name

Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner Phone Number*

Please enter a valid phone number.

Co-Owner Phone Number

Please enter a valid phone number.

Owner Email Address*

example@example.com

Co-Owner Email Address

example@example.com

How would you prefer to receive reminders?*

EmailTextBoth Are Fine

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

How did you hear about us?*

If Shelter/Rescue/Client/Employee/Other Hospital/Doctor, who can we thank for the referral?*

Pet Name*

Pet Birthdate or Age (If Known)

Color/Description*

Species*

DogCatOther

Breed*

Sex*

MaleFemale

Spayed/Neutered*

YesNo

Microchipped?*

YesNo

Do you have an appointment for your pet? If yes, please provide your scheduled date and time.

What is the reason for your visit?*

Please list any medical conditions your pet has:

Do you have another pet to add?

YesNo

Pet Name*

Pet Birthdate or Age (If Know)

Color/Description*

Species*

DogCatOther

Breed*

Sex*

MaleFemale

Spayed/Neutered*

YesNo

Microchipped*

YesNo

Do you have an appointment for your pet? If yes, please provide your scheduled date and time.

What is the reason for your visit?*

Please list any medical conditions your pet has:

Do you have another pet to add?*

YesNo

Pet Name*

Pet Birthdate or Age (If Know)

Color/Description*

Species*

DogCatOther

Breed*

Sex*

MaleFemale

Spayed/Neutered*

YesNo

Microchipped*

YesNo

Do you have an appointment for your pet? If yes, please provide your scheduled date and time.

What is the reason for your visit?*

Please list any medical conditions your pet has:

Do you have another pet to add?*

YesNo

Pet Name*

Pet Birthdate or Age (If Know)

Color/Description*

Species*

DogCatOther

Breed*

Sex*

MaleFemale

Spayed/Neutered*

YesNo

Microchipped*

YesNo

Do you have an appointment for your pet? If yes, please provide your scheduled date and time.

What is the reason for your visit?*

Please list any medical conditions your pet has:

If you have medical records for your pet(s), please upload them here. These records help us provide the best care for your pet(s) by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.

Please note that payment is required in full at the time services are rendered. If you have any questions or concerns regarding payment, please feel free to contact us before your appointment. Thank you for your understanding and cooperation.

I hereby grant Fairview Heights Animal Clinic & Animal Hospital of O'Fallon permission to use my testimonial or likeness in a photograph, video, or other digital media ("Photo") in any and all of its publications, including web-based publications, without payment or other consideration, for purposes of advertising the hospital staff or services.

I understand and agree that all photos will become the property of the Fairview Heights Animal Clinic & Animal Hospital of O'Fallon, and will not be returned.

I hereby irrevocably authorize Fairview Heights Animal Clinic & Animal Hospital of O'Fallon to edit, alter, copy, exhibit, publish, or distribute any testimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonial or likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial or Photo.

I hereby hold harmless, release, and forever discharge the Fairview Heights Animal Clinic & Animal Hospital of O'Fallon from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.*

I agreeI do NOT agree

(Owner) Parent or Guardian Name*

First NameLast Name

(Owner) Parent or Guardian Signature*

Today's Date*

Date

New Client Form

Pet Information

Pet #1

Pet #2

Pet #3

Pet #4

Payment Policy

Social Media Release