New Client Form - Kingsland

Client Information

We keep all Client Information Confidential

Date*

Owner Name*

Address

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

Home Phone

Cell Phone*

Work Phone

Email*

In case of emergency and we cannot contact you, who should we contact?*

Communication Consent – Do we have permission to contact you using one of the below communication methods? Choose all that apply.*

Home Address
Email
Home Phone
Work Phone

Media Consent – I grant Kingsland Blvd Animal Clinic and its representatives/employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically.*

How did you hear about us?*

If other, please explain. If referral, please let us know whom we can thank.

Pet Information

Name*

Species*

If Other, list species.*

Breed*

Color*

Birthday/Age*

Sex*

Spayed/Neutered*

Known Allergies*

Microchipped*

Microchip Number

Pet Food*

Medications/Supplements*

Should your pet be muzzled?*

Has your pet ever bitten anyone?*

†We will need proof of vaccines for our records. ††We will request records.

Previous Veteriarian††*

Dog Vaccines

For dogs, please confirm which vaccines are current for your pet.

Rabies Vaccine

DHLPP Vaccine (The "Distemper Shot")

Bordetella Vaccine

Canine Influenza H3N8 Vaccine

Leptospirosis Vaccine

Cat Vaccines

For cats, please confirm which vaccines are current for your pet.

Rabies Vaccine

FVRCP Vaccine

Feline 2-FeLV (Protection against Feline Leukemia) Vaccine

FIP (Feline Infectious Peritonitis) Vaccine

Authorization

Permission to share your records with Other Hospitals/Emergency/Specialty.*

Permission to share your records with Groomers/Daycare.*

Permission to share your records with Pet Insurance.*

Authorization*

AUTHORIZATION: I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Kingsland Blvd Animal Clinic for the treatment of care. I hereby consent and authorize Kingsland Blvd Animal Clinic to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. All animals staying must be current on all vaccines and be free of external and internal parasites. We reserve the right to update vaccines and treat parasites as needed at the owner’s expense. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Kingsland Blvd Animal Clinic. If in the event that the animal is not picked up, there will be a notice of 10-days to come claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. We accept debit cards, credit cards (Visa, Mastercard, Discover, American Express), checks, and cash. Our hospital accepts third-party payment plans, including CareCredit and Scratchpay. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.

Owner/Responsible Party*

Date **

Comments

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