Client Information Form Client Information Form Name * Name First First Last Last Spouse / Other Name Spouse / Other Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone * Other Phone Email * Employer * Work Phone * Please select one of the options below * Cat Care Clinic can call my work number for general correspondence regarding my cat(s) Cat Care Clinic should only call my work number in the event of a medical emergency How did you learn about Cat Care Clinic? * Internet Search Cat Care Clinic Sign / Driving By Daytona Tortugas / Jackie Robinson Ballpark Referred by a Client of the Hospital Referred by another Veterinarian Local Event OtherOther If so, who? * Which Event? * In the event that Cat Care Clinic is contacted by another veterinary medical facility for my cat’s records or vaccination history, I authorize the release of those records. * Yes No I, the undersigned owner or authorized agent of the cat identified herein, hereby consent to the examination and treatment of the indicated cat(s) and I assume responsibility for all charges. I understand that I have the right and duty to discuss any charges prior to treatment. I also understand that if payment is not made as agreed, my account will be turned over to a debt collection agency and all legal and collection expenses will be added to my total bill. Full Payment is due upon release of patient. A deposit may be required for admitted patients. We accept all major credit cards as well as Care Credit. Sorry, but we cannot accept checks on your first visit. Signature * signature keyboard Clear Date * If you are human, leave this field blank. Next
