New Patient Registration

CLIENT (HUMAN) INFORMATION *

First Name Last Name

Address *

Street Address

Apt Number

City State / Province

Postal / Zip Code

Email Address *

Cell Phone *

Home Phone *

Work Phone *

Preferred method(s) of contact: *

Cell phone Work Phone Home Phone Email Mail

Current Employer

Secondary Contact

First Name Last Name

Relationship

Cell Phone

Work Phone

How did you hear about us?

*

AUTHORIZATION & RELEASE FOR MEDICAL and/or SURGICAL CARE I, the undersigned as owner and/or agent of the animal(s), do attest that I am at least 18 years old and do hereby authorize the veterinarians of Family Animal Medicine, PLLC and such persons as they designate as their aids and assistants to administer to the patient such diagnostic, therapeutic, anesthetic and/or surgical procedure as they deem necessary for the care of said animal. I hereby certify that I have read and fully understand the above authorization. I also certify that no guarantee or assurance has been made as to results that may be obtained and I completely release any staff veterinarian their aids, assistants, and Family Animal Medicine, PLLC from any and all liability due to death, loss, or any decline in condition of my animal while under their care. I also understand and agree to the terms of payment: all fees are due and payable at the time services are rendered.

SIGNATURE *

Clear