Patient/Client Information Form Owner’s Name* First Last Spouse/Other First Last Address* 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile #*Home Phone #*Work #*E-mail Address* Employer’s NamePet's InformationPet’s Name** Male Female Spayed/Neutered Intact Species*Breed*Color*Birth date*********** Professional Fees are due at the time services are rendered **********Method of Payment:*CashCheckDebitVisa/MasterCard (credit card fee will apply)How did you hear about us?Previous veterinarianWhom may we thank for referring you?For safety reasons, Companion Animal Hospital requests that clients do not restrain their pets during the examination or medical procedures. I understand that if I choose to restrain my pet, I do so at my own risk and will not hold Companion Animal Hospital liable for any injuries (human or animal) that may result. In order to prevent the spread of infectious disease and external parasites, all animals admitted into the hospital facility must be current on all vaccinations and be parasitefree. Rabies vaccination is required by State Law. I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon this pet and additional pets that I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharge from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee will be assessed for each non-sufficient fund check and/or certified letter that must be sent and monthly service charge fees shall accrue to any unpaid balances. I understand that Companion Animal Hospital is not a 24-hour care facility and veterinary service is dependent upon business hours. Continuous presence of qualified personnel may not be provided. Evening, weekend, holiday and critical care veterinary services are performed at one of the two local emergency hospitals. If I neglect to pick up my pet within 5 days of the discharge and do not notify you within that time period, you may assume that the pet is abandoned and hereby authorized to dispose of the pet as you deem best and/or necessary. I authorize Companion Animal Hospital to contact other veterinarians to discuss medical issues concerning my pet and to obtain medical records for my pet. I also authorize Companion Animal hospital to release medical records to other veterinary hospitals and to release the vaccination history to boarding/grooming facilities. I understand that Companion Animal Hospital occasionally uses video/audio surveillance for training purposes. Companion Animal Hospital occasionally utilizes various modes of social media (Facebook, BLOG, Twitter, etc) to connect with clients. Only your pet’s name, photograph and possibly brief medical information are used. No client information is used unless specific permission is givenSocial media consentI authorize my pet’s photo/information to be used (INITIAL)I do NOT authorize my pet’s photo/information to be used (INITIAL)Date* Date Format: MM slash DD slash YYYY Signature*NameThis field is for validation purposes and should be left unchanged.
