New Client InfoSheet Submission - Aztec Animal Clinic

Your name*

First Middle Initial Last

Date of Birth*

Last 4 Digits of Social Security Number*

Spouse/Partner

First Last

Today's Date*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Work Phone

Email

Drivers Lic#:

Employer’s Name

Spouse’s/Partner’s Employer

Spouse’s/Partner’s Work Phone

May we contact you by Email?*

Yes
No

How did you hear about our hospital?

Individual, someone we may thank?

Other

About your pet

Pet’s name*

Species*

Breed*

Color*

DOB (or approximate age)*

Sex:*

Male
Female
Spayed Female
Male Neutered

Date of last vaccines*

Any existing medical problems?*

Add another pet?

Yes
No

Pet’s name*

Breed*

Color*

DOB (or approximate age)*

Sex:*

Male
Female
Spayed Female
Male Neutered

Date of last vaccines*

Any existing medical problems?*

Add a third pet?

Yes
No

Pet’s name*

Breed*

Color*

DOB (or approximate age)*

Sex:*

Male
Female
Spayed Female
Male Neutered

Date of last vaccines*

Any existing medical problems?*

I understand payment is due at time of service. Cash , check, Visa, Mastercard, and Discover are accepted. All accounts thirty (30) days past due may be charged an interest rate in the amount of 1.5% or a minimum of $5.00 per month. In the event that my account becomes delinquent, it may be sent to a collection agency. In addition, I may be charged a one-time fee of 15% or $15.00, whichever is greatest if my account is sent to a collection agency.

I grant Aztec Animal Clinic irrevocable and unrestricted permission to use any photos taken at the clinic of me, my pets, and any minors accompanying me to Aztec Animal Clinic. Aztec Animal Clinic may use and/or publish such photos in any and all media now or here after known, including in printed and digital materials without restriction. I release and discharge Aztec Animal Clinic from any and all claims and demands that may arise out of or in connection with said photographs, including without limitation any and all claims for libel or violation of any right of publicity or privacy.

I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.

Signature*

Date*

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