caringvets.com - New Client Information

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following. Please note: we will not sell any of your information to outside companies.

Name

SPOUSE/ OTHER

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HOME PHONE

Please enter a valid phone number.

CELL

Please enter a valid phone number.

EMAIL ADDRESS

example@example.com

EMPLOYER

EMPLOYER STREET ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EMPLOYER PHONE

Please enter a valid phone number.

EXTENSION

OWNER’S DRIVER’S LICENSE

# (kept confidential - for check writing privileges only)

STATE

HOW DID YOU FIRST HEAR ABOUT THE ANIMAL HOSPITAL OF SUSSEX COUNTY?

OR, WHOM MAY WE THANK FOR REFERRING YOU?

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

I request that Animal Hospital of Sussex County, Inc.’s doctors and staff perform the services which are necessary to the examination and medical treatment of the animal(s) presented by me. I am the owner or agent for the owner of the described animal(s) and have authority to execute this consent. Provider is hereinafter understood to mean Animal ospital of Sussex County, Inc., its veterinarians, agents, and employees.
I authorize the veterinarians on duty (and assistants they may designate) to examine the animal(s) and to administer medical treatment or emergency care which is considered therapeutically and/ or diagnostically necessary on the basis of the examination findings. I, therefore, hereby consent to and authorize the performance of such procedures as deemed necessary and desirable in the veterinarian’s professional judgment.
I understand that the treatment of the patient(s) will be conducted with due care and in accordance with the prevailing standards of care in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the Provider.
Accounts over 30 days past due shall pay interest at the maximum legal rate. I agree to pay all attorney’s fees, interest, collection costs and other costs of litigation incurred in the collection of past due accounts.
The Provider shall not be responsible for the loss, theft or destruction of any personal property left with my pet(s).
I understand that an estimate may be provided at my request. I also consent to the release of medical information to other authorized veterinary and/ or boarding facilities.
I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge.
I authorize any person with possession of the described animal(s) in addition to myself to request veterinary care for the described animal( s) and have the authorization to make medical decisions for the described animal(s) in my absence. I n addition, I understand all services/ products rendered by that person will be my financial responsibility.

SIGNATURE OF OWNER OR RESPONSIBLE AGENT

Clear

Date

New Client Information

OWNER INFORMATION

Animal Medical History

VACCINATION HISTORY (PLEASE GIVE DATES OF LAST VACCINATIONS)

Animal Medical History

VACCINATION HISTORY (PLEASE GIVE DATES OF LAST VACCINATIONS)