New Patient Registration

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 *

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