Sangaree Animal Hospital New Client Form

Name*

First NameLast Name

Appointment Date*

Date

Birthdate

Date

Primary Email*

example@example.com

Secondary Email

example@example.com

Employer Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home/Main Phone #*

Please enter a valid phone number.

Cell Phone #

Please enter a valid phone number.

Work Phone #

Please enter a valid phone number.

Name

First NameLast Name

Email

example@example.com

Employer Name

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Sangaree Animal Hospital provides all clients with online Pet Portal account access. Through the Pet Portal you can access your pet’s medical information, order product(s), and more. We must collect at least one e-mail address in order to provide access to the Pet Portal. We also periodically send informative e-newsletters using this information. Your contact information will never be sold to a third-party and is used exclusively by Sangaree Animal Hospital. If you have any questions regarding these policies, please feel free to ask a receptionist.

How Many Pets Do You Have?

Pet #1 Name*

Birthdate*

Date

Species

DogCatOther

Gender

MaleFemale

Spayed/Neutered

YesNo

Breed

Color

Microchipped

YesNo

Microchip Number (if applicable)

Does your pet have any special needs? If so, please elaborate here:

Pet #2 Name*

Birthdate*

Date

Species

DogCatOther

Gender

MaleFemale

Spayed/Neutered

YesNo

Breed

Color

Microchipped

YesNo

Microchip Number (if applicable)

Does your pet have any special needs? If so, please elaborate here:

Pet #3 Name*

Birthdate*

Date

Species

DogCatOther

Gender

MaleFemale

Spayed/Neutered

YesNo

Breed

Color

Microchipped

YesNo

Microchip Number (if applicable)

Does your pet have any special needs? If so, please elaborate here:

Pet #4 Name*

Birthdate*

Date

Species

DogCatOther

Gender

MaleFemale

Spayed/Neutered

YesNo

Breed

Color

Microchipped

YesNo

Microchip Number (if applicable)

Does your pet have any special needs? If so, please elaborate here:

Pet #5 Name*

Birthdate*

Date

Species

DogCatOther

Gender

MaleFemale

Spayed/Neutered

YesNo

Breed

Color

Microchipped

YesNo

Microchip Number (if applicable)

Does your pet have any special needs? If so, please elaborate here:

Where & when was your pet(s) last vaccinated?

Do you hereby grant Sangaree Animal Hospital permission to obtain previous veterinary medical records for your pet(s)?*

YesNoNot Applicable

If yes, from where?*

Phone #

I authorize the release of my pets vaccine history to a kennel, veterinary rescue, or grooming facility without notification.*

YesNo

How Did You Find Us?*

Which Pet Shop/Groomer/Breeder?

Which SPCA/Animal Shelter?

Which other Hospital/Doctor?

I hereby grant Sangaree Animal Hospital 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 Sangaree Animal Hospital, and will not be returned.

I hereby irrevocably authorize the Sangaree Animal Hospital 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 Sangaree Animal Hospital 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 ACCEPT:

Do you grant permission for the use of your photo or a testimonial?*

Yes - if yes, please sign belowNo

Signature for Testimonial & Photo Release*

Date*

Date

I hereby agree that all of the above information is correct to the best of my knowledge, and I assume responsibility for the animal(s) listed.*

Date*

Date

New Client Form

Client Information

Spouse/Co-Owner Information

Secondary Spouse Or Other

Pet Information

Pet Information - Pet #1

Pet Information - Pet #2

Pet Information - Pet #3

Pet Information - Pet #4

Pet Information - Pet #5

Veterinary Care Information

Referral Information

Testimonial & Photo Release

New Client Signature