New Client Information Form

Name: Veterinarian
Brand: Rice Village Animal Hospital

First Name

Last Name

Pronouns

She/Her

He/Him

They/Them

Address 1

Address 2

City

State/Province

Country

Zip Code

Home Phone

Work Phone

Cell Phone

E-mail

First Name

Last Name

Work Phone

Cell Phone

E-mail

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Hospital Policies

Our hospital will not release your pet to any person not specifically authorized by you. Please list all persons you wish to pre-authorize for receiving your pet:

Do you authorize us to obtain information about your pet(s) from another veterinarian, kennel, breeder or any other person?

Yes

Do you give permission for Rice Village Animal Hospital to take and display photographs of your pet(s) on their website, Facebook page or in their Hospital?

Yes

Our hospital requires that every pet left in our care is to be current on Rabies vaccine as determined by our veterinary staff. Treatment or vaccines will be administered at the expense of the owner, including doctor’s exam fees.

I have read and understand

Payment for services is due at the time the pet is released. We accept Master Card, Visa, Discover, American Express, Care Credit, cash and checks.

I have read and understand

Date

Your signature here verifies that you have read and understand all the above information.

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New Client Information Form

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