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Client Information Form

"*" indicates required fields

Client Information

Owner's First Name*

Owner's Last Name*

Spouse

Pet's Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email*

Medical Information Release

Please Choose One with your initials

I authorize AllPets Animal Clinic to release medical information on my pet(s) to another veterinary clinic, local law enforcement (e.g.: in the case of rabies vaccination verification), boarding facilities/groomers requesting vaccination and laboratory history or pet insurance company.

Please Initial

I prefer to personally contact AllPets Animal Clinic to release medical information on my pet(s) to another veterinary clinic, local law enforcement (in the case of rabies vaccination verification), boarding facilities/groomers requesting vaccination and laboratory history or pet insurance company.

Please Initial

Social Media Permission

Social Media Permission*

YES! You may use my pet(s) photo

NO! You may NOT use my pet(s) photo

Signature of Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the pet(s) on my account, I assume responsibility for all charges. incurred for the care of my pet(s) authorized by myself and/or others listed on my account (spouse). I also understand that these charges will be paid at the time of service/release.

Signature*

Date*

Comments

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