Prairie Lane Veterinary Hospital - Updated Client Information Form

Client Information Form
Client Information
Owner Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place Of Employment
Business Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
E-mail*
example@example.com
Spouse’s Name
Spouse's Phone
Please enter a valid phone number.
Preferred Method of Contact

TextPhone CallEmail
Please let us know if you, your family members, or your pet are allergic to peanuts.

YesNo
I grant Prairie Lane Veterinary Hospital, its representative and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Prairie Lane Veterinary Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content.*

The above may take photos of me and/or my pet.The above may NOT take photos of me and/or my pet.
Can we give vaccine information to your groomer, pet daycare, rescue, or boarding facility?

YesNo
Financial Policy Acceptance

I understand that all professional fees are due at the time services are rendered. By signing below, I assume responsibility for all charges incurred in the care of my animal(s).
ScribbleVet Consent and Release
Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:
1. Appointment Recording: You agree that your vet appointments may be
  recorded. If you don’t want to be recorded, let us know.
2. Usage Rights: You grant us permission to share these recordings, and any
  other materials you choose to provide, for the purpose of improved clinical
  documentation.
3. Age Confirmation & Understanding: You affirm that you are at least eighteen
  years old, and that you understand and accept the terms in this agreement.
  We are committed to providing the best care for your pet in a manner comfortable for both of you.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Information Form

Client Information

Financial Policy Acceptance

ScribbleVet Consent and Release