New Client Form – Hollow Creek Animal Hospital

HOLLOW CREEK ANIMAL HOSPITAL CLIENT INFORMATION

Client Name*

First Last

Spouse Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Consent

Please initial here if we have your permission to send text messages to your mobile phone.

We will not send frequent
messages but, we would like to be able to communicate with you when your pet is here for a surgical procedure, appointment, or when
your pet’s medication/food is ready to be picked up.

Email*

Spouse Email

How did you find out about us? (Family/Friend, Online Search)*

Can we thank anyone in particular for recommending us?

PET INFORMATION

Pet's Name*

Breed*

Age/Date of Birth*

Color*

Sex*

Is your pet spayed or neutered?*

Yes
No
Is scheduled to be

Has your pet been vaccinated in the last 12 months? If so, where?*

Is your pet on any medications (including heartworm and flea/tick control)?*

Are there other pets in the household? If so, please list*

Consent

Consent for the disclosure and use of images.

By initialing I consent to the use of my pet’s image for purposes including, but not limited, to the Hollow Creek Animal Hospital Website and Facebook page.

Payment is due in full at the time of discharge.

Required if paying by check: Driver’s License

There is a $35 charge for any returned check and it will be sent to the Worthless Check Unit for collection.

Your D.O.B.

Owner's Release*

I agree to the below policy & use this consent box as a digital signature.

Owner’s Release: You are to use all reasonable precaution against injury, escape, or death of my pet. The hospital and staff will not
be held liable for problems that develop provided reasonable care and precautions are followed. I understand that any issue that
develops with my pet in my absence will be treated as deemed best by the veterinarian on duty and I assume all responsibility for the
expenses for treatment. If I neglect to pick up my pet after 7 days of the scheduled release date and do not notify you within that time
period, you may assume that the pet is abandoned, therefore the property of Hollow Creek Animal Hospital, and you are hereby
authorized to make decisions for the pet as necessary

Today's Date

HOLLOW CREEK ANIMAL HOSPITAL CLIENT INFORMATION

PET INFORMATION

Payment is due in full at the time of discharge.

Get In Touch

Email: [email protected]

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