New/Updated Client Form

Name*

First Last

Email*

Co-Owner/Spouse Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone

Home Phone

Place of Employment

Spouse's Place of Employment

Spouse's Phone

Driver's License # & Issuance State

Date of Birth*

Gender*

Female
Male
Prefer not to say

Needed before dispensing controlled drugs for your pet

Under 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 individuals

Please list the other individuals

Social 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.

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How did you become aware of our clinic?

Personal 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*

Email

This field is for validation purposes and should be left unchanged.

Under 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.

***ALL FEES ARE DUE AT TIME SERVICES ARE RENDERED***

ALL FEES ARE DUE AT TIME SERVICES ARE RENDERED