Client Information UpdatePrimary Contact Name(Required) First Last Primary Contact Phone Number(Required)Primary Contact Email Address(Required) Secondary Contact Name First Last Secondary Contact Phone NumberAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pet InformationPet's name #1(Required)Species(Required) Dog CatGender(Required) Male – Intact Male- Neutered Female – Intact Female – Spayed UnknownAge / DOB(Required)Breed(Required)Color(Required)Any Other Pets?(Required) Yes No2nd PetPet's name #2(Required)Species(Required) Dog CatGender(Required) Male – Intact Male- Neutered Female – Intact Female – Spayed UnknownAge / DOB(Required)Breed(Required)Color(Required)This field is hidden when viewing the formSection BreakDo you currently have Pet Insurance?(Required) No Yes – List Insurance Company No but would like to learn morePhotograph and Video Release: There may be times we would like to share a photo or video of your pet with our social media sites (Ex/ website, Facebook, Instagram, etc.)(Required) Yes, you may use my pet’s photo No thank youNotification Settings – We use text messages and email to communicate appointment reminders, as well as your pet's health reminders (vaccines, exams, etc), and occasional clinic notices. If you would like to opt OUT of these reminders, please indicate below.(Required) Email and Text OK TEXT OPT OUT- you may not receive appointment updates EMAIL OPT OUT- you may not be alerted when your pet is due for vaccines OPT OUT of BOTH Email and Text notificationsI, the undersigned, am the owner or agent for the owner of the animal(s) described, and I have the full and exclusive authority to execute this consent.I certify that I am 18 years of age or older.I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.I agree to pay for all services rendered and medications, goods, and supplies when purchased.I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.Pet Insurance is encouraged. Visit Pawlicy Advisor for more information.If desired, financing options are available through SunBit, CareCredit and Scratchpay.I understand that a deposit may be required for surgical or medical treatment.Irelease this hospital from any and all liabilities.By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of this agreement upon request.Owner/Agent Signature(Required)Is there anything else you'd like us to know?Did you know we have a Pet Portal? Here, you can view your pet’s recent health history, download vaccine certificates, request refills, request appointments, and more! Visit our website to learn more!Financial PolicyPlease review our financial policy.If you have any questions, please ask any member of our team.Payment is expected at the completion of each visit.Checks are not accepted as a form of payment.We do not bill for services.If you need a payment plan for a procedure, please ask about our third-party financial lenders, which can support payment plans if needed.Pre-approval for financing can be completed in just a few minutes, without credit impact, online or with assistance from our CSR team.New clients will require a deposit to hold their appointment.The deposit will remain as a credit toward appointment charges.Note: If the appointment is canceled or rescheduled with less than 24 hours’ notice, the deposit will be forfeited and required again for future scheduling.Deposits are required for all surgeries and hospitalized pets.Pet insurance is recommended.Check out Pawlicy Advisor for more information.Payment is due at the time of service; depending on your insurance plan, you may be reimbursed after filing.We can assist you in filing your claim for insurance reimbursement.Accepted forms of payment (with proper identification): Cash, MasterCard, Visa, Discover, American Express, G-Pay, Apple Pay, Care Credit, Scratch Pay, SunbitWe will review a medical treatment plan (cost estimate) with you in advance of all wellness care, diagnostic, surgical procedures, or non-routine work-ups.We want you to feel comfortable discussing your financial concerns with us so we can help you maximize the health of your pet.Acknowledgement of Financial Policy I certify I have read and fully understand the financial policy and that payment in full is due at the time of services.Please indicate you have reviewed this policy. Your signature below indicates that the information you have provided us with today is accurate and you have read and understand our financial policy.Δ
