Owner(s) Information

Primary Owner’s Name*

First Last

Email*

How did you hear about us?*

Referral*

Name of person

Online*

Google, Yelp

Other*

Facebook, Instagram

Co-owner/Spouse

First Last

Mailing Address

Street Address City ZIP Code

Phone Number (Primary)*

Co-owner (Secondary)

Best Ways To Contact You*

Patient(s) Information

Pet(s) Information*

Name	Species (Dog, Cat, Other)	Breed	Male / Female	Spayed/Neutered	Color Or Markings	DOB / Age	Insurance?

Current Veterinarian/Clinic*

Consent*

I have read and agree to the terms.

Please read carefully and indicate your consent below:

I hereby grant permission for the release of any or all of the information contained in the medical record of my pet(s), listed above, to be given upon request to another veterinary practice or other party by fax, surface mail or by email. This release will remain in effect until otherwise notified by you in writing of desired changes.
I hereby consent to the use of my name, my pet’s name, and photographs or videos of myself and/or my pet for any lawful purpose, including publicity, illustrations, website, and social media.
I hereby authorize the veterinarian to examine, prescribe for, and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. WE DO NOT BILL.

Date*