Client Information Sheet Welcome to San Carlos Animal Hospital. Thank you for giving us the opportunity to care for your pet. So we may become better acquainted, please complete the following: Dr. Acosta and Dr. Altman both worked at Sunset Cliffs Animal Hospital in Ocean Beach, prior to coming here.Have you ever been a client of Sunset Cliffs Animal Hospital in Ocean Beach, San Diego?*YESNOif yes, please sign below*If yes, I certify that I have not been called on, solicited, directly or indirectly or been influenced in any way by any officer, employee or representative of San Carlos Animal Hospital and I have come here out of my own free will.*Please print full name*Client InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhonePreferred Phone Number*HomeCellWorkEmail* Drivers license#*DOB* Occupation*How did you hear about us?Spouse/Partner/Co-owner name First Last PhoneName First Last Patient InformationPet 1 Name*Pet 1 Birth Date*Pet 1 Species*CanineFelinePet 1 Breed*Pet 1 Breed*Pet 1 Color*Pet 1 Sex*MaleFemalePet 1*SpayedNeuteredUnalteredPet 2 NamePet 2 Birth DatePet 2 SpeciesCanineFelinePet 2 ColorPet 2 SexMaleFemalePet 2SpayedNeuteredUnalteredPet 3 NamePet 3 Birth DatePet 3 SpeciesCanineFelinePet 3 ColorPet 3 SexMaleFemalePet 3SpayedNeuteredUnalteredPet 4 NamePet 4 Birth DatePet 4 SpeciesCanineFelinePet 4 ColorPet 4 SexMaleFemalePet 4SpayedNeuteredUnalteredIf you have cats, do any of them go outsideDo any of the above pets have any known allergies (medications, insect bites, food, vaccines)? If so, which one and please explainMay we have your permission to post photos of your pets on social media sites such as Facebook and Instagram?*YesNoPlease read carefully before signing*Please read carefully before signingI certify that if I am or have been a former client of Sunset Cliffs Animal Hospital I have not been called on, solicited, directly or indirectly or been influenced in any way by any officer, employee or representative of San Carlos Animal Hospital and I have come here out of my own free will.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.Date* EmailThis field is for validation purposes and should be left unchanged.