Name First Last For the purpose of prescribing controlled medication, we need your date of birth MM slash DD slash YYYY Spouse/Partner/Co-Owner Name: Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (Must use physical location, P.O Boxes are not accepted)Mailing address if different than above: Mobile Number* Alternate Number:Email* Preferred method for us to contact you with pet health status: Call Text Email Who can we thank for referring you?GoogleYelpDrive ByVin JonsCountry CareSocial MediaWhich One? Facebook Youtube Instagram Other Dr. Preference **The highest compliment you can give us is to refer your friends to us! You will receive one FREE Paw Stamp on your account. Once you receive 20 Paw Stamps, you are awarded $100 to spend on applicable services at your next visit with us as a THANK YOU for the referral. If you download our app, you will receive one FREE Paw Stamp! Please ask for more details. Do you have a pet sitter, neighbor, relative, or friend who is authorized to bring in pet (s) and make treatment decisions in your absence?Name First Last Relationship PhoneWe would like to know a little about your furry family. Please fill out below.1st Pet’s Name: Age Color Breed Sex Male Female Spayed/ Neutered Yes No Chronic medical condition OR current medication (including flea/tick/heartworm prevention):2nd Pet’s Name: Age Color Breed Sex Male Female Spayed/ Neutered Yes No Chronic medical condition OR current medication (including flea/tick/heartworm prevention):*If you have more than two pets at home, please fill out an additional form*If you have more than two pets at home, please ask for an additional formPlease carefully read each of the following statements. If you completely understand and agree to the terms listed, please check where provided. Please ask our staff if you have any questions. I hereby certify that I am the owner or an authorized agent of the owner for the above- named pet (s) and I am over the age of eighteen. I also authorize the Hospital Medical Director and the staff to provide veterinary services as requested, or in emergency circumstances, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis, until further advised in writing. I understand personal items (blankets, toys, etc.) may not be returned if left at Imperial Highway Animal Clinic. I understand that payment is required in FULL at the time services are rendered. I understand that I may be asked to leave a deposit before services, surgical or other, and that no guarantee can be given to the outcome. I understand Imperial Highway Animal Clinic accepts Cash, Visa, MC, Discover, American Express, CareCredit and Scratch Pay as the only forms of payment. I am aware and understand that IHAC does NOT provide 24-hour staffing on premises. Social Media Release: I grant Imperial Highway Animal Clinic and its employees the right to take and save photographs my pet(s) and agree that they may use photographs of my pet(s) and his or her given name.Please check next to your permission for use of: Text messaging to cell number provided on my account/record Posting on Imperial Highway Animal Clinic’s social media channels/pages and website. ** I wish to be tagged (when possible) in social media posts including my pet(s) images. **Please Note: Occasional we like to post adorable pictures of our client’s pets to our Facebook and Instagram page or our website! Client Privacy is of the utmost importance to us at Imperial Highway Animal Clinic. Your first and last name will not be disclosed or printed at any time; unless you wish to be tagged. We are asking permission to share, print, post and reference your pet’s name and picture only. Declaration: If my account should become delinquent, I am responsible for valid collection costs & attorney fees. A finance charge of 1.5% per month (or $8.00) charge, which is greater is due on all balances owed over 30 days. Insufficient funds aka bounced check fee is $45 per incident. SignaturePhoneThis field is for validation purposes and should be left unchanged.
