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Driver’s License # (if paying by check):
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E-Mail Address: (required) :
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Employer: (required)
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In case of an emergency, please list an additional point of contact, and their phone number: (required)
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How did you become aware of our clinic? (Check all that apply) (required)
Our yard sign
Yellow pages
Internet
Another client
Other
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Please list all pets including their species (cat, dog, etc.) (required)
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Authorization:
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of the pet(s). I also understand that all professional fees are due at the time services are rendered. Northview Animal Hospital has a website (http://northviewpetcare.com) and a Facebook Page which we use as a source of education for our clients and information about our practice. We occasionally post photos of our patients there. Although the pet’s first name may be mentioned, no client information would ever be shared. If, at any time, you wish to have your pet’s photo removed, please alert us and the photo(s) of your pet will be promptly removed. |
Do we have permission to use your pet’s photo? (required)
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I agree that all of the above information is correct and that I have read this form in it's entirety: (required)
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Today's Date: (required)
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Method of payment" (required)
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