Country Club Animal Hospital - New Client Information Form

Thank you for your interest in Country Club Animal Hospital. We look forward to getting to know you and having the opportunity to care for your pet(s). Please fill out the information sheet completely.

Pet Owner

Spouse/Partner

Owner's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Owner's Email

Phone

Mobile

Other

Emergency Contact

Emergency Phone

Consumer information is not shared with third parties for marketing purposes.

How did you hear about our hospital? Check all that apply

Used our services before

Saw our hospital

Internet search

Facebook/ Social Media

Recommended by friend

Who may we thank?

Pet Information

Pet Name:

Species (dog/cat/other):

Breed (Doberman /Siamese):

Description (Color/markings):

Sex (Male/Female):

Age (Months/Years):

Altered/ Spayed:

Microchip number:

Help us lern more about your pet

Do you have pet insurance? If yes, which one?

My dog goes to the dog park and plays with other dogs

Or My cat goes outside (free roaming, only with supervision

Has your pet been known to bite? (please explain)

My pet boards at a kennel

My pet goes to the groomer regularly

My pet is currently/will be attending obedience school

Are there any specific questions or concerns you would like us to address at your visit today?

PHOTO CONSENT: Do we have your permission to share your pet’s image and story on social media, our website & other forms of related media? Your name and personal information will never be shared.

Yes. I authorize CCAH to share my pet’s photo & story

NO. I do not authorize this.

Health Records:

Previous health care provider:

Please indicate date of last veterinary visit/procedure/vaccines given:

Any chronic health conditions?

Any history of vaccine reactions?

Current medications:

Current heartworm/ flea prevention:

MEDICAL RECORDS RELEASE POLICY:

Following guidelines set forth by the American Animal Hospital Association (AAHA) it is our goal to maintain confidentiality and respect client/ patient confidentiality. In order to comply with the current standard directing the release of your pet's medical records, we must have your written consent to transfer, copy or transmit, either a portion or an account history in its entirety, from our hospital (i.e.; boarding facilities, referral clinics, city officials, etc.).

I authorize Country Club Animal Hospital, to release/disclose my pets: Please check one

Full Medical Records

Vaccine History Only

DO NOT Release Records

I understand that there may be a fee associated with the copying, faxing, mailing and handling of my request.

Owner Signature

Date

CONSENT FOR EMERGENCIES/RELEASE OF MEDICAL INFORMATION:

I give permission for the individuals named below to obtain medical information for my pet(s) and to seek emergency treatment for my pet(s) in the event that I am unable to do so. I understand that, as the owner, I am financially responsible for any and all services rendered.

Name

Phone Number

Name

Phone Number

TERMS OF SERVICE:

PAYMENT IN FULL is required at the time services are rendered. We accept cash, checks, Visa, MasterCard, Discover, and Care Credit as forms of payment.

I, the undersigned, agree to pay for veterinary services in a timely manner. I understand that services on accounts unpaid after 30 days will be charged a monthly service fee. If you have an account over 90 days past due, Country Club Animal Hospital may relinquish your balance owed to a collection agency. Country Club Animal Hospital charges $25 for returned checks. I agree to be responsible for payment of all collection and attorney fees incurred should this account be submitted for collection.

Owner's Signature

Date

Print Name

Date

CCAH Witness to Signature:

Date