New Client/ Patient Registration Form

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MAY THIS PERSON MAKE DECISIONS ON YOUR BEHALF/ IN YOUR ABSENCE? *
MAY WE SEND EMAIL CONCERNING YOUR PET’S CARE INCLUDING REMINDERS FOR APPOINTMENTS/SERVICES DUE? *
MAY WE SEND EMAIL CONCERNING YOUR PET’S CARE INCLUDING REMINDERS FOR APPOINTMENTS/SERVICES DUE? *
MAY WE USE PHOTOS OF YOUR PET(S) ON OUR MARKETING MATERIALS/ WEBSITE & SOCIAL MEDIA? *
HOW DID YOU HEAR ABOUT US?
 
GENERAL INFORMATION *
MY PET IS UP TO DATE ON BASIC VACCINATIONS (DISTEMPER/PARVO/RABIES FOR DOGS, DISTEMPER/ UPPER RESPIRATORY/RABIES FOR CATS)*PLEASE NOTE THAT MANY PETS REQUIRE ADDITIONAL VACCINATIONS FOR FULLEST PROTECTION DEPENDING ON THEIR CIRCUMSTANCES *
HAS YOUR PET HAD ANY MAJOR MEDICAL PROBLEMS IN THE PAST OR CURRENTLY? (PLEASE DESCRIBE BRIEFLY) *
CURRENT MEDICATIONS *
 
HAVE/ WILL YOU REQUEST THAT YOUR PET’S VETERINARY PATIENT RECORDS BE FORWARDED TO CCMVS? *
HOW DO YOU PLAN TO PAY FOR SERVICES? * CHECKS ONLY ACCEPTED BY ESTABLISHED CLIENTS AFTER 2 VISITS *
 
* IF THIS ACCOUNT IS TURNED OVER FOR COLLECTION YOU ARE RESPONSIBLE FOR COURT COSTS AND ATTORNEY FEES IN ADDTION FO ANY REAMAINING BALANCE.
I hereby authorize the veterinarian of Cherished Companion Mobile Veterinary Services, LLC. To examine, prescribe for and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that treatment and medications will be discussed and approved at the time that services are provided. I understand that these charges must be paid at the time that services are provided.