Information Form

Client Information Form

Client Information

Owner's First Name *

Owner's Last Name *

Spouse

Pet's Name *

Address

State *

Address *

City *

Zip / Postal code *

Phone *

Email *

Medical Information Release

Please Choose One *

I authorize AllPets Animal Clinic to release medical information on my pet(s) to another veterinary clinic, local law enforcement (e.g.: in the case of rabies vaccination verification), boarding facilities/groomers requesting vaccination and laboratory history or pet insurance company.I prefer to personally contact AllPets Animal Clinic to release medical information on my pet(s) to another veterinary clinic, local law enforcement (in the case of rabies vaccination verification), boarding facilities/groomers requesting vaccination and laboratory history or pet insurance company.

Social Media Permission

Social Media Permission *

YES! You may use my pet(s) photoNO! You may NOT use my pet(s) photo

Signature of Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the pet(s) on my account, I assume responsibility for all charges.
incurred for the care of my pet(s) authorized by myself and/or others listed on my account (spouse). I also understand that these charges will be
paid at the time of service/release.

Type your Signature

Client Information Form