Client Information

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Work Phone

Email *

**Note: by filling out the Co-Owner section below, you authorize that person to make decisions regarding your pet’s care.**

**Co-Owner or Spouse Name

First

Last

How did you learn of our clinic?

Sign
Social Media
Referred/Recommended
Other

Please Specify: *

Referred/Recommended by: *

Pet Information

Pet's Name *

Species *

Breed *

Color *

Sex *

Spay/Neuter? *

Age or DOB? *

Microchipped? *

Do You Have a Second Pet? *

Yes
No

Professional Fees Are to Be Paid at Time Services Are Rendered

Authorization *

I acknowledge that I am the owner of the pet(s) listed above. I hereby authorize the veterinarian to examine, prescribe for, or treat the pet(s) listed above. I am at least eighteen (18) years of age and I assume total financial responsibility for the cost of services rendered by Companion Animal Medical Center. I also understand that these charges will be paid at the time of check out and that a deposit may be required for surgical treatment.

Marketing Release Consent

We love sharing our patients on Facebook, Instagram, and other marketing materials — but only with your permission. By consenting below, you authorize Companion Animal Medical Center to photograph and/or video your pet and use images, videos, your pet’s name, and portions of your pet’s story for social media, website, educational, advertising, and other promotional purposes. I understand these materials may be published in print and/or electronically. *

Yes, I consent.
No, I do not consent.

I agree that Companion Animal Medical Center may use such photographs, videos or stories including me and/or my pet with or without names and for any lawful purpose, including for example such purposes as social media, publicity, advertising, and other Web content. *

Yes, I consent.
No, I do not consent.

Date *

Printed Name *

Signature of Owner *

Clear Signature

First Visit Paperwork

Making Your First Visit

Simple, Smooth & Stress-Free

Client Information

Pet Information

Marketing Release Consent

Ready to Visit?

We Can’t Wait to Hear from You!

Contact Info

Location

Hours