New Client Information Form Owner's Name(s) * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone * (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Can we reach you by text? * Yes No Were you referred to us? * Yes No Who referred you to us? Name of Patient * First Name Last Name Patient Sex * Male Female Species * Breed * Age / Date of Birth * Color(s) / Markings * Do you have other pets in the house? * Yes No Please list the species of your other pets. * Please list other past or current Veterinary providers. * What is the reason for this visit? * Authorization and consent for services * I verify that all information contained in this document is correct and current. I will notify Como Park Animal Hospital of any changes to my contact or ownership information. I authorize that I am the owner of this patient, that I am at least 18 years of age and that I have the authority to authorize medical care for this pet - surgery, diagnostics, treatments, and euthanasia – to be performed by Como Park Animal Hospital, or AfterHours Veterinary Care on their behalf. I agree Medical Records Release * I give consent to release medical records for this patient. We will still ask for verbal authorization and a reason for transfer of records. This is for protection of your privacy and security of legal medical information. I agree Payment for all services are due at time of services performed. * I understand that I am financially responsible for all services rendered. A deposit may be required for certain medical or surgical procedures. The hospital accepts payment by Cash, Tele-Check, Visa, MasterCard, Discover, American Express, CareCredit, and Scratchpay. A $35.00 service fee will be applied to all returned checks. Balances over thirty days will be subject to interest at the rate of 1.5% per month. I understand that if the balance is not paid in a timely fashion, I will be responsible not only for the balance due, but any collection agency fees, court costs, and/or attorney fees that are incurred in the attempt to collect this debt. I agree Legal Responsibility * By signing below I assume full legal and financial responsibility for the above listed pet. I agree Electronic Signature * By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. I agree to the privacy policy. Thank you!