New Client Information FormWe appreciate your confidence in the care we provide for your pet and your family. Owners Name * First Name Last Name Spouse/Partner * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number (###) ### #### Spouse/Partner Phone (###) ### #### Email * Would you like to receive text message updates during your pet's stay? Yes No Preferred Pharmacy Pharmacy Phone Number (###) ### #### Owner's Birth Date (for outside prescription reasons) MM DD YYYY Emergency Contact: (this contact is someone to contact if you have an emergency) First Name Last Name Phone (###) ### #### How did you hear about us? Referring Veterinarian Referred By Another Client Location Sign Facebook Google/Internet Website Yellow Pages If referred by another client, whom may we thank? We love sharing our patients’ sweet faces! Do we have your permission to share your pet's image on social media and/or our website? Your name and personal information will never be shared. Yes. I authorize Veterinary Specialist of Hanover to share my pet's photo and first name of pet. No. I do not authorize Veterinary Specialist of Hanover to share my pet's photo and first name of pet. I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for 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 treatment. Type your name here to sign Thank you!
