Client Information Form
Client Information
Owner Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / 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
Text
Phone Call
Email
Please let us know if you, your family members, or your pet are allergic to peanuts.
Yes
No
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?
Yes
No
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).
Signature
Date
-
Month
-
Day
Year
Date
Submit
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