Client Information Sheet

Name*
First MI Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Owner DOB*
MM slash DD slash YYYY

This is required for controlled medication.
Email*
Occupation*
How did you hear about us?
Spouse/Partner/Co-owner name
Phone*
Patient Information*
Name Birthdate Species Breed Color Gender Spayed/Neutered
If you have cats, do any of them go outside?
- Yes
- No
Do any of the above pets have any known allergies (medications, insect bites, food, vaccines)? If so, which one and please explain,
May we have your permission to post photos of your pets on social media sites such as Facebook and Instagram?*
- Yes
- No
Please read carefully before signing
I understand that professional fees are to be paid in full at the time services are rendered.

I authorize San Carlos Animal Hospital to provide medical services for my pets.

I, the owner or authorizing agent of the patients described above, assume full responsibility for all charges incurred regardless of the outcome of the patients’ treatment.

In the case of an emergency I authorize San Carlos Animal Hospital to start life-saving procedures.
Signature*
Date*
MM slash DD slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Name	Birthdate	Species	Breed	Color	Gender	Spayed/Neutered

Please read carefully before signing