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Client Information Form

Primary Account Holder

Name(Required)

First

Last

Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Email(Required)

Primary Phone Number(Required)

Secondary Account Holder

(This individual will have full authority to make decisions on treatments and can request pet’s records)

Name

First

Last

Email

Address

Street Address

Address Line 2

City

State

ZIP Code

Secondary Phone Number

Pet Information (#1)

Name

Age / Birthday

Species

Canine

Feline

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

No

Not Sure

Allergies

Yes

No

Pet Information (#2)

Name

Age / Birthday

Species

Canine

Feline

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

No

Not Sure

Allergies

Yes

No

Pet Information (#3)

Name

Age / Birthday

Species

Canine

Feline

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

No

Not Sure

Allergies

Yes

No

Policy Acknowledgement

Please read and select the following

Social Media Policy

Social Media Policy: I allow Cordova Animal Medical Center to use my pet’s photo for promotional purposes (Facebook, website).

Cancellation/Rescheduling/No-show Policy:

Cancellation/Rescheduling/No-show Policy: I understand that if I am unable to keep an appointment, I must notify the office 24 hours in advance to either cancel or reschedule. If I am unable to give proper notice for three appointments within a 12-month period, I will be asked to prepay the exam fee to schedule another appointment. This prepayment is non-refundable and non-transferable to a different date.

Tardy Policy

Tardy Policy: I understand that if I arrive 5 minutes past my scheduled appointment time, I may be asked to reschedule and any deposit made will be forfeited (see above policy).

Outside Pharmacy Policy

Outside Pharmacy Policy: CAMC does not call/fax/email prescriptions to outside pharmacies, including online pharmacies such as Chewy and 1800PetMeds – it is the owner responsibility to submit the written prescription to the pharmacy. If you choose to have the prescription filled with a local human pharmacy, please ensure that the pharmacy will accept a prescription WITHOUT and NPI or DEA license number on it. Our veterinarians license numbers are printed on the prescription and are all that is legally required for a veterinarian to prescribe non-controlled substances. CAMC will not respond to inquiries from pharmacies requesting an NPI or DEA number for a non-controlled substance.

Payment Policy

Payment Policy: Payment in full is required at the time of service. For your convenience, we accept all major credit cards and cash. We also accept Care Credit and Scratch pay (low to no interest rates) in case of emergency. A deposit will be required for all major surgeries and hospitalization of your pet. Returned checks are subject to a $35 fee. By signing this document, I agree that I am responsible for payment of all services rendered, and if payment becomes past due, it is subject to an interest rate of 18% and is eligible to be sent to collections.

Signature

Date(Required)