Current ClientsPlease update your information below. Client Section Name * First Name Last Name Spouse (Other) Name First Name Last Name What is Spouse (Other)'s relationship to you? Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Phone * (###) ### #### Work Phone (###) ### #### Spouse (Other) Phone Number (###) ### #### Email * How would you like us to contact you for appointment reminders? * Phone Call Text How would you like us to remind you when your pet is due for vaccinations/exam/tests? * Email Text Phone call Drivers License Number (For check writing.) How did you hear about us? (Please list any names so we can thank them for their referral!) * Are you one of the following? (ID will be verified upon arrival) * Military Law Enforcement Firefighter Paramedic None of the above. Media Release Authorization * Pet owners and their pets are often photographed for use in Davis Animal Hospital promotional materials and publicity efforts. These photographs may be used in a publication, print ad, direct-mail piece, electronic media (e. g. video, CD-ROM, Internet/World-Wide Web)or other form of promotion. By selecting yes you release Davis Animal Hospital and all employees from liability for any violation of any personal or proprietary right in connection with such use. I give permission. I do not give permission without contacting me first. Medical Inquiry & Release Authorization * I give permission for the doctors and staff of Davis Animal Hospital to release or inquire about necessary medical information and vaccination status concerning my pet from other animal care professionals such as other veterinary hospitals, animal control, boarding facilities, grooming facilities, rescue or shelter organizations or other related animal care professionals. Current vaccination status may also be obtained from us by the health department or landlord. I give permission. I do not give permission without contacting me first. Treatment Authorization * I am the owner/authorized agent for the animal named above, and I am 18 years of age or older. I give permission for the doctors and staff of Davis Animal Hospital to examine and treat my pet as I have requested. I understand that medical therapy of any kind involves some risk to my pet, including but not limited to adverse drug reactions, and agree to hold the hospital and its employees harmless in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event of an emergency I understand that life saving measures will be initiated while an attempt is made to contact me. If I cannot be contacted at the listed numbers, the doctors and staff are directed to make decisions deemed best for my pet. I understand that payment is due when services are rendered, and I agree to pay for those services rendered. I understand that interest will accrue on any balance outstanding over 30 days at 1.5% per month (18% annually) and a $5.00 handling fee will be assessed on each monthly statement. I agree to pay for these and any additional cost incurred by the hospital in the collection of any outstanding debt for services rendered. I agree to the above. E-Signature * Typing my initials confirms that the above information is accurate to the best of my knowledge. Thank you!Your form has been submitted for review. When you come in for your next appointment, we will have a secondary form for you to review and sign.
