Client Information Form

Thank you for giving us the opportunity to care for your pet. To ensure the best care possible, please take the time to fill in this form completely. Thank you.

REGISTRATION

YesNo
Animal PlanetLocationOtherWKTVHumane SocietyNHAH WebsiteVeterinarians.comWeb SearchYellow Pages

YesNo
YesNo
YesNo

PET HEALTH HISTORY

PET 1

DogCatOther


PET 2

DogCatOther If other, please list:





PET 3

DogCatOther If other, please list:

INSURANCE INFORMATION

Do you have pet health insurance?

If yes, please provide us with a blank claim form

AUTHORIZATIONS

Your pet's medical information is protected by law. We are legally obligated to not release any information to any individual including groomers, boarding facilities, etc. without your permission.

Please CHOOSE and SELECT one of the following:

Authorized Agents in Owner(s) Absence:

Please list below any person(s) other than yourself or spouse/other that you authorize to make decisions regarding the care of your pet. These people will be authorized to bring your pet in care and authorize emergency medical treatment in the event that you cannot be contacted after reasonable attempts. Be aware that you are still financially responsible for all care provided.

Authorized Agent Name   Telephone Number   Relationship to Owner

I do not authorize any person(s) to act as my agent in my absence regarding medical care of my pet.

Photo Release:

I authorize New Hartford Animal Hospital to use any photos/videos obtained of my pet for marketing purposes.

I certify that I am the owner of this patient or the authorized agent of the owner, and that I am over the age of 18. I hereby authorize the New Hartford Animal Hospital & Care Center to perform any necessary treatments or services on the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges will be paid at the time of release and that a deposit may be required for hospitalization or surgical treatment.
Accepted Methods of Payment: CASH?CHECK?MasterCard? Visa? Discover?Care Credit American Express

Submission of this form indicates that you verify the information provided is accurate and that you agree to the terms.