CLIENT INFORMATION

Client Name *

First

Last

Spouse/Alternate Contact

First

Last

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your mailing address different from the street address? *

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Secondary Phone

Spouse/Alternate Phone

Employer

Work Phone

Email Address *

Do you agree to receive text messages from Creekside Animal Hospital? *

I agree

By checking this box, you consent to receive informational and/or promotional text messages from Creekside Animal Hospital at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help.

Information Review *

I have reviewed the above information and confirm it is accurate.

PATIENT (PET) INFORMATION

Pet's Name *

Sex *

Male
Female
Male - Neutered
Female - Spayed

Date of Birth *

Breed *

Color

Vaccinated in the past year? *

Yes
No
Unsure

Where? *

I give my permission to share my pet’s medical records/information with the following (check all that apply) *

Boarding/Grooming Facilities
Other Veterinarian Clinics (including but not limited to specialty practices)
Animal Control/Law Enforcement
Rescue/Shelter Groups
Other (Please Specify)
None of the Above

If other, please specify: *

Photo Consent *

I hereby grant Creekside Animal Hospital & Wellness Center permission to use my pet or my pet's likeness in photographs/videos in any and all of its publications and in any and all other media, where now known or hereafter existing. I will make no monetary or other claim against Creekside Animal Hospital & Wellness Center for their use.
I DO NOT grant Creekside Animal Hospital & Wellness Center permission to use my pet’s likeness in any photos, videos, publications, or media.

How did you hear about us?

If you were referred, who may we thank? *

If other, please specify: *

Terms & Conditions: Payment is due when services are rendered. Creekside Animal Hospital and Wellness Center reserves the right to assess collection and/or attorney fees associated with non-payment. The client agrees to pay any and all court/attorney fees necessary to enforce this agreement. *

I have read and agree to the terms and conditions.

Signature *

Clear Signature

Today's Date *

New Client Form at Creekside Animal Hospital

Welcome to Creekside Animal Hospital!

CLIENT INFORMATION

PATIENT (PET) INFORMATION

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