New Client Form in Lacey, WA | Dermatology Clinic for Animals

New Client Form

Owner #1*
Owner #2*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
(Home Phone)Cell #1
Can we send you text messages?
- Yes
- No
Cell #2
Can we send you text messages?
- Yes
- No
May we contact you by Email?
- Yes
- No
Email
Driver's License
Employer
Name of Veterinary Hospital you take your pet to?
Pet Information
Name of Pet
- Dog
- Cat
Breed
Age/DOB
- Male
- Female
Color
Spayed / Neutered?
- Yes
- No
Medications your pet is taking now?
Other pets in the Household:
List
Name Specie Breed Age
I do authorize Dermatology Clinic for Animals to obtain pictures of my pet in order to document the skin condition and/or for teaching purposes or publication.*
- Yes
- No
I authorize and direct the veterinarians at Dermatology Clinic for Animals to diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well-being.No warranty or guarantee has been made as to the result or cure.
Appointment Cancellation Policy:Dermatology Clinic for Animals is committed to providing all of our patients with exceptional care. Please call (253) 596-5093 two business days prior to canceling your appointment or procedure to allow another patient to be seen. If prior notification is not given, you will be required to prepay future visits. Scheduling an intradermal allergy test or video otoscopy will require a non-refundable deposit of $150. Thank you for helping us continue to offer exceptional care for your pet.
Signature of Owner*
Date*
MM slash DD slash YYYY

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Pet Information

Other pets in the Household:

Name	Specie	Breed	Age