Client Intake Form

Date*

Name*

First Last

Primary Phone*

Secondary Phone

Spouse/Partner Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Work Phone

Email*

Driver's License #*

Driver's License State*

Driver's License Expiration Date*

Date of Birth*

Emergency Contact Phone*

Photo Release*

You may take and use photographs of my pet without the use of my name for any purpose such as social media and web content.

Yes, you may use photos!
No, maybe another time.

Consent*

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We will gladly provide you with a written estimate at your request. Please ask the receptionist or veterinarian. In an effort to control costs, we do not provide billing services and require payment at the time services are rendered. A deposit may be required depending on the cost and involvement of some procedures. Should a bill for services become delinquent, I agree to be responsible for any court costs or attorney fees.

TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED AND BOARDED ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE FROM INTERNAL AND EXTERNAL PARASITES.

I agree to the terms above.

How did you hear about our hospital?

Individual, someone we may thank?
Google/Social Media
AHAA referral
Drive by

Client Intake Form

Hours

Address