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
How did you hear about us?
Referring Veterinarian
Veterinary Hospital
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.
All fees are required to be paid in full upon completion of the visit. For your convenience we accept VISA, Mastercard, Discover, Care Credit, Cash, and Checks. Sorry, We do not accept American Express.
In the event any balance due here under is not paid as agreed, the undersigned jointly and severally agree to pay all cost included in said unpaid balance, including a reasonable collection and/or attorney’s fees.
Signature of Owner*
Date*
MM slash DD slash YYYY

Name	Specie	Breed	Age