CLIENT INFORMATION FORM

"*" indicates required fields

Client Information

Owner's First Name

Owner's Last Name

Spouse

Pet's Name

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Medical Information Release

Please Choose One

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.

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.

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

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