972-636-9562
general@cfvc.net
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972-636-9562
general@cfvc.net
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Client Forms
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Client Name (Human Info)
*
First
Last
Home Phone
*
Cellular Phone (Self):
*
Work Phone (Self):
Email
*
Employer:
Address
*
Address Line 1
Address Line 2
City
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Texas
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West Virginia
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Wyoming
State
Zip Code
Date of Birth
*
Spouse's / Co-owner's Name:
First
Last
Spouse's/Co-owner's Employer:
Cellular Phone (Spouse/Co-owner):
Work Phone (Spouse/Co-owner):
Pet Emergency Contact Name and Number: (you authorize us to speak to this person about your pet's care in the event we cannot reach you.)
*
How did you hear about us?
*
What social media platforms do you use?
Facebook
Twitter
Pinterest
Instagram
LinkedIn
Google+
Other
If Other, please specify.
All fees are due at the time services are rendered.
Driver's License Number:
*
State:
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Expiration Date:
*
Our office accepts Visa, Mastercard, Discover, Scratch Pay, Care Credit and Cash Full payment is due at the time of service. Clients with payment concerns are asked to speak to a Client Service Representative prior to appointment.
*
Yes, I need financing options.
No, I do not need financing options.
Click here
to learn more about all of our payment options.
Photo Consent: We love social media! Do we have your permission to share your pet(s)' image and/or story on social media, our website & other forms of related media? Simply check below to authorize this:
Yes. I authorize CFVC to share my pet's photo & story at any time.
No. I do not authorize this.
Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the below described pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express permission.
*
I have read and authorize.
Some of our exam rooms are monitored with audio and video recordings which may be used for training purposes. Your signature below authorizes your consent to these recordings.
*
I have read and understand.
Digital Signature (Name)
*
Today's Date
*
Pet #1 Name
*
Pet #1 Date of Birth or Age:
*
Pet #1 Species
*
Dog
Cat
Other
Pet #1 Breed
*
Pet #1 Sex:
*
Male
Female
Has your pet been spayed or neutered?
*
Yes
No
Unsure
Vaccinations were last given by (please include the clinic name and date):
*
Has your pet been microchipped? If yes, please also include the microchip number.
*
Allergies or Long-term Medical Problems:
*
Pet #2 Name
Pet #2 Date of Birth or Age:
Pet #2 Species
Dog
Cat
Other
Pet #2 Breed
Pet #2 Sex:
Male
Female
Has your pet been spayed or neutered?
Yes
No
Unsure
Vaccinations were last given by (please include the clinic name and date):
Has your pet been microchipped? If yes, please also include the microchip number.
Allergies or Long-term Medical Problems:
Pet #3 Name
Pet #3 Date of Birth or Age:
Pet #3 Species
Dog
Cat
Other
Pet #3 Breed
Pet #3 Sex:
Male
Female
Has your pet been spayed or neutered?
Yes
No
Unsure
Vaccinations were last given by (please include the clinic name and date):
Has your pet been microchipped? If yes, please also include the microchip number.
Allergies or Long-term Medical Problems:
Name
Submit