Client Information Update Form

Client Information

Primary Client Name *

First

Last

What are your preferred pronouns *

She/Her/Hers
He/Him/His
They/Them/Theirs
Other

List Other

Ownership *

I am the sole owner/caregiver of the below listed pet(s)
I share ownership/responsibility of the below listed pet(s)

Cell Phone Number *

(we ask that your primary phone be a cell phone number as we will text appointment confirmations and reminders)

Alternate Phone Number

Is this number for:

Home
Cell
Work

Email *

Communication Preference *

Phone Call
Text
Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Client Name *

First

Last

Preferred Pronouns *

She/Her/Hers
He/Him/His
They/Them/Theirs
Other

If other, please specify *

Phone *

Relationship to Primary Client *

Do you have pet insurance? *

Yes
No

What company? *

Authorization

Photo Release – I authorize Health & Harmony Animal Hospital to take photographs of my pet and to copyright, use and publish them in print and/or electronically. This could include purposes such as social media, website and newsletters. My name will not be used but my pet’s name may or may not be included. *

Yes
No

Records Release – I authorize the release of my pet’s medical records to another facility (boarding/daycare/emergency hospital, etc) should they be requested. *

Yes
No

Payment & Fee Schedule - We accept cash, credit/debit cards (Visa, Mastercard, Discover, Amex) and Care Credit. At your request, we will gladly discuss and/or prepare a written estimate of treatment costs. I understand that payment for all services rendered is due at time of service and that a deposit may be required for surgeries or hospitalization. *

I understand and agree to these terms

Authorization - I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal and certify that I am the rightful owner of the above listed animal(s). *

I understand and agree to these terms

Signature *

Date *

Client Information Update Form

We are honored that you have chosen us to take care of your beloved pet. Please fill out the form below to update our client database information. (Note: this form is for current active clients only, if you are a new client please visit this link)

Client Information

Authorization