Client Information Form | Cordova Animal Medical Center

Primary Account Holder

Name(Required)

First

Last

Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Email(Required)

Home Phone(Required)

Cell Phone(Required)

Preferred method of communication?(Required)

Text Message

Phone Call

By selecting text messaging, you are agreeing to receive text messages from our hospital.

Secondary Account Holder

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

Relationship

Name

First

Last

Address

Street Address

Address Line 2

City

State

ZIP Code

Home Phone

Cell Phone

Emergency Contact

Name

First

Last

Relationship

Phone

How did you hear about us?

If Personal Referral (Who can we thank?)

How much information do you want to be given about your pet’s health?(Required)

I want a full explanation – anything and everything.

I want a brief explanation – just the important stuff.

I just want to know if there’s anything I need to do – keep it simple.

Pet Information (#1)

Name

Age / Birthday

Species

Dog

Cat

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

Not Sure

Allergies

Yes

Pet Information (#2)

Name

Age / Birthday

Species

Dog

Cat

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

Not Sure

Allergies

Yes

Pet Information (#3)

Name

Age / Birthday

Species

Dog

Cat

Other

Breed

Color

Sex

Male

Female

Spayed or Neutered

Yes

Not Sure

Allergies

Yes

Please initial here if you will allow Cordova Animal Medical Center to use your pet's photo for our promotional purposes (website and social media)

If you are not able to keep an appointment, please notify our office 24 hours in advance to cancel or to reschedule your appointment. This will enable us to help you with another appointment and to fill your slot with another patient in need.
If you are Ten minutes (or more) late, you have forfeited the appointment time and are subject to be rescheduled. If you do not come to your scheduled appointment and/or givue us less than the required notice time, two times, you will be required to prepay for all upcoming visits.

Payment

Payment is required at the time of service. For your convenience, we accept Mastercard, Visa, American Express, cash, or check (with a valid driver’s license). A deposit may be required for surgical procedures or hospitalization of your pet. Returned checks are subject to a $35.00 fee. By signing this document, you agree that you are responsible for payment of all services rendered and that if payment becomes past due, it is subject to an interest rate of 18%.

Signature(Required)

Date(Required)

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