& Print Form - Liberty Veterinary Medical Center

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New Client & Patient Form
Client Name: _____________________ Spouse’s Name: _____________________
Address: ______________________________ City: _______________________ Zip: _________
Home Phone: ___________________ Cell Phone: _______________________ Other: __________
Email Address (Please provide an email Address for Reminders):
[email protected]___________._________
SSN #: ______________________
Place of Employment: _______________________________ Work Phone: ___________________
If Military – Rank: ___________________________________ Unit: __________________________
Spouse’s Place of Employment: _______________________ Work Phone: ___________________
If Military – Rank: ___________________________________ Unit: __________________________
Patient Name: _____________________ Species: Feline/Canine
Breed: ____________________________ Sex: Male/Female
Altered/Unaltered
Age/D.O.B.: ___________________________ Markings: __________________________
Color: ____________________ Current Diet (Food Brand): _______________________________
Please list below any past/current medical problems or known sensitivities to medications,
vaccinations, or food. Also list current medications, including heartworm or flea/tick control:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
*For the safety of our staff and clients, please alert us if your pet is people aggressive, or has bitten
any person.
Clinic Policy: Payment is due to be paid in full at time services are rendered.
- For delayed payment options, we offer Care Credit.
*We accept all major credit cards, cash, & debit cards.
Is anyone else other than yourself authorized to make medical decisions or approve treatments for
your pet(s)? If Yes – Name: _______________________ Phone: _____________
The information provided is accurate to the best of my knowledge. I hereby authorize Liberty
Veterinary Medical Center to provide medical care/treatment for my listed pet(s) from this date
forward and I understand the payment policy.
_______________________________________
Signature
_______________________________
Date
I authorize Liberty Veterinary Medical Center to take photos of my pet(s) and use for any lawful
purpose, including, publicity purposes, illustration, advertising, and web/social media content.
_______________________________________
Signature
_______________________________
Date
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