New Client Form Date Date Format: MM slash DD slash YYYY Client Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Home PhoneEmail* Spouse/Partner/Co-Owner First Last Cell PhoneHome PhoneEmail 405 Vet Animal Hospital emails reminders to clients. May we also text you reminders?YesNoPATIENT INFORMATIONName*List*Age or DOBSpeciesColorBreedChoose oneIntact MaleIntact FemaleNeutered MaleSpayed FemaleDate of Last VaccinesVeterinary ClinicVeterinary ClinicCurrent MedicationsNameListAge or DOBSpeciesColorBreedChoose oneIntact MaleIntact FemaleNeutered MaleSpayed FemaleDate of Last VaccinesVeterinary ClinicCurrent MedicationsWe want your pet to be Facebook famous, but we need your permission first.Yes-I consentNo-I do not consentI grant permission to 405 Vet Animal Hospital, its employees and authorized representatives to take photographs and/ or video of me and/or my pet(s), to use and publish the same in print and/or electronically. This might include. for example, such purposes as social media and other Web content.I understand there will be an initial consultation fee and agree to this fee. It is understood that a treatment plan will be presented to me that will. include any additional recommended treatments, diagnostics, or procedures and all cost associated with those services. I understand that no guarantee or assurance can be made as to the results that may be obtained. It is thoroughly understood that I assume all risks involved with any treatments, surgeries, or procedures. I understand that professional fees are due at the time services are rendered.I have read and agree to the above statementsDigital SIgnature