New Client Form

Owners Information:

First name:

Last name:

Spouse/Other:

Driver License Number:

Email address:

Address:

Suite/Apt#:

City:

State

Zipcode:

Home Number:

Mobile Number:

Work Number:

Fax Number:

Pet Information:

Pet Name:

Date of Birth:

Breed

Color:

Microchip Number:

Diet:

Feeding:

Current Heartworm and Flea Prevention:

Previous Medical History:

Current Medications:

Other

How do you hear about us:

If a friend/family member referred you, please let us know who, so that we can thank them:

Medical Information Release

I authorize any health care information to be released to only the following Person(s), Boarding/Grooming facilities Veterinarians, Specialists or Emergency Clinics:

Name/Establishment Name:

Phone Number:

Name/Establishment Name:

Phone Number:

Name/Establishment Name:

Phone Number:

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all the charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical or medical treatment. If for whatever reason I do not pay my balance at the time of service I understand that El Cid Animal Clinic has 30 days before they can place my account in collections. During these 30 days my account my also acquire late fees and interests. Once my account has been placed in collections I will be held responsible for any fees charged to El Cid Animal Clinic in their attempts to collect my balance. I certify that I am the owner of the above named pet, I am 18 years of age or older, and do hereby consent and authorize El Cid Animal Clinic and its staff to care for, hospitalize my pet for procedures, anesthetics or other treatment that the doctor deems necessary for the health and safety of the above named animal while under the care and supervision of the clinic. If my pet should injure itself in an attempt to break free from restraint, refuse food, soil it-self, becomes ill or dies while in the hospital, I will hold El Cid Animal Clinic free of any responsibility or liability in the absence of gross negligence. I further realize that I am responsible for payment of the above procedure and treatment(s) in full at the time my pet is discharged. If I neglect to pick up the pet within ten (10) days of written notice that is ready for release, we may assume the pet was abandoned. El Cid Animal Clinic will then be authorized to dispose of the pet as the clinic deems fit. Abandonment does not release me of my financial obligations to pay any bill.

We would like to post pictures of your pet on EL Cid Animal Clinic’s Facebook and share it with you. Please initial for your consent to upload photos:

Initial:

*Please, note we do not accept checks as a form of payment.

Office Policies

For safety reasons, all dogs must be restrained on a leash and all cats must be in carrier when entering our clinic.

Payment Options:

• Payment is due when services are rendered.
We accept all major Credit Cards, Cash and Care Credit as a form of payment.
• Credit Cards must match driver’s license and person present.
• If you have someone else come in for you and want that person to use your credit card, please fill out the attached page with your credit card information.

Returns/Refunds:

• Refunds can be credited back to either your account or back on to your credit card.
• If a return is necessary and you have paid with a credit card, please bring in the same credit card you used for the purchase.
• All prescription drugs cannot be returned, once they leave our hospital.
• Food products can be returned within 30 days.

Drop-off Requirements:

• All pets must be up-to-date with their vaccines. For dogs, Rabies, Distemper, Parvo, Lepto and Bordetella. For cats, Rabies Feline Viral Rhinotracheitis, Calici Calici Virus, Panleukopenia, Feline Leukemia.
• All boarders will be given a Capstar upon arrival and departure from our clinic. This is to prevent flea infestation for both your home and El Cid Animal Clinic.

Owner Signature:

Date:

SUBMIT