New/Updated Client Form Name* First Last Email* Co-Owner/Spouse Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhonePlace of EmploymentSpouse's Place of EmploymentSpouse's PhoneDriver's License # & Issuance StateDate of Birth*Gender* Female Male Prefer not to sayNeeded before dispensing controlled drugs for your petUnder the laws of HPAA (Health Insurance Portability and Accountability Act), we can not disclose any personal information about you or your pet to anyone unless otherwise specified by you except as required by state and local health authorities.Would you like to consent to the release of medical information for your pet(s) to the following:* Other Veterinary/boarding/grooming facilities Shelters/rescue groups Other individualsPlease list the other individualsSocial Media release*I grant to Central Veterinary Hospital, its representatives and employees the right to take photographs or videos of me, my pet(s) and my property. I authorize Central Veterinary Hospital, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I also agree that Central Veterinary Hospital may use such photographs or videos of me with or without my name for lawful purpose, including such purposes as publicity, illustration, advertising, and Web content. Approve DeclineHow did you become aware of our clinic?Drove ByPrevious ClientInternetPersonal Recommendation (Whom may we thank?)***ALL FEES ARE DUE AT TIME SERVICES ARE RENDERED***In order to help keep costs down and to continue to provide the highest quality of veterinary medicine, Central Veterinary Hospital requires payment in full at the time services are rendered. For your convenience, we accept Cash, Check, Visa, MasterCard, Discover, American Express, and CareCredit (please ask a receptionist for more details). I understand that the treatment of my pet(s) will be conducted with due care and in accordance with AAHA standards in veterinary medicine. I understand that no guarantee or assurance has been or will be made as to the results that may be obtained through the course of treatment undertaken by the veterinarians, agents, or employees of Central Veterinary Hospital. In the event that I default on payment, I will be responsible for all monthly service charges (18%), collection charges (33%), attorney fees or court costs incurred by the hospital. I understand that a written estimate of charges is always available within reasonable time of my request.Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
