New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Co-Owner Email:

Relationship:

We send communications, reminders and appointment reminders by text and email. Do you want this feature?*

Yes

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color/Markings

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Allergies?

Yes

If "YES", please list:

General Information

Previous Veterinarian and Phone Number

Do you give permission to Countryside Animal Clinic to obtain medical records?*

Yes

For future reference, do you give Countryside Animal Clinic permission to release medical records to other veterinary/speciality, boarding, grooming and daycare centers?*

Yes

How did you hear about us?

Internet Search

Facebook

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

I hereby grant Countryside Animal Clinic permission to use any photographs taken of myself or my pet, in any and all of its publications, including website entries and Facebook, without payment of any compensation. I understand and agree that these materials will become property of Countryside Animal Clinic and will not be returned. I hereby authorize Countryside Animal Clinic to edit, alter, copy, exhibit, or publish, or distribute photos for purposes of publicizing their programs or for any other lawful purpose. In addition I waive all claims, demands, and causes to action which I, my heirs, representatives executors administrators or any other person acting on my behalf of my estate have or may have by reason of this authorization. In signing this consent, I give authorization to use my name and my pet’s name as printed below.*

Yes

Payment is required after services are rendered. We accept cash, check, credit/debit cards, Care Credit and Scratch Pay.

By signing this document, I accept financial responsibility and medical treatments provided for my pets by Countryside Animal Clinic.

New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Co-Owner Email:

Relationship:

We send communications, reminders and appointment reminders by text and email. Do you want this feature?*

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color/Markings

Sex

Allergies?

If "YES", please list:

General Information

Previous Veterinarian and Phone Number

Do you give permission to Countryside Animal Clinic to obtain medical records?*

For future reference, do you give Countryside Animal Clinic permission to release medical records to other veterinary/speciality, boarding, grooming and daycare centers?*

How did you hear about us?

If you were referred by a client, what is their name?

Payment is required after services are rendered. We accept cash, check, credit/debit cards, Care Credit and Scratch Pay. By signing this document, I accept financial responsibility and medical treatments provided for my pets by Countryside Animal Clinic.

Signature:

Payment is required after services are rendered. We accept cash, check, credit/debit cards, Care Credit and Scratch Pay.

By signing this document, I accept financial responsibility and medical treatments provided for my pets by Countryside Animal Clinic.