Client Forms - Country Friends Veterinary Clinic

Client Name (Human Info) *

First

Last

Home Phone *

Cellular Phone (Self): *

Work Phone (Self):

Email *

Employer:

Address *

Address Line 1

Address Line 2

City

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?

If Other, please specify.

All fees are due at the time services are rendered.

Driver's License Number: *

State: *

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: