Client Information Form

Client’s full name

Address

P O Box

City

State

Zip

Home Phone

Cell Phone

Place of Employment

Work Phone

E-Mail Address

Spouse’s Phone

Spouse’s Name

Regular Veterinarian

Clinic Name

We keep in touch with our clients by: Text, Email or Phone Calls - Which number should we use

Have you been to this hospital before:

Yes No

What is your pet’s name?

Is Your pet?

Dog Cat

Breed

Sex

Male Female

Neutered/Spayed?

Yes No

Age

Has your pet required a muzzle for previous veterinary visits?

Yes No

Weight (by our staff)

Reason for this visit

Allergies, special problems, medications

Is Rabies Vaccine Up to Date

We keep in touch with our clients by: Text, Email or Phone Calls -

I am the owner or agent of the owner of the above-described animal (s) and have the authority to execute this consent. I hereby consent and authorize performance of the procedures or operations as explained to me by Veterinary Emergency Services. I understand that no one under the age of 18 can authorize services.

Yes No

EMERGENCY VETERINARY PROCEDURES I understand that during the performance of the foregoing procedure (s) or operation (s), unforeseen conditions may be revealed that necessitate an extension of foregoing procedure (s) or operation (s) or different procedure (s) or operation(s) than those set above. Therefore, I hereby consent to and authorize the performance of such procedure (s) or operation (s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I authorize the use of appropriate anesthetics and other medication and I understand hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure (s) or operation (s) and the risks involved. I realize that results cannot be guaranteed.

Yes No

Which method of payment will you be using ( We do not accept checks)

If my account becomes delinquent, I understand that I am responsible for all expenses, including an interest charge of 18% on the unpaid balance, attorney fees and all court costs. I have read and understand the foregoing. I authorize and consent to the treatment required and the terms contained herein.

Yes No

Signature:

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