New Client Information Form -

New Client information Form

If you are a new client of Aspire Veterinary Center, please fill out this form and press submit.

OWNER INFORMATION

Are you a NEW or EXISTING Client of Aspire Veterinary Center? *NEWEXISTING

Are you at least 18 years of age? *YesNoPlease ensure that the Owners on this form are at least 18 years of age (the legal age of an adult in California).

Owner's First Name *

Owner's Last Name *

How many owners are there for your pet(s)? *12

Primary Owner

Owner's First Name *

Owner's Last Name *

Home Address *

Apartment #, Suite #, etc.

City *

State/Province *

ZIP / Postal Code *

Owner's Email Address *

Owner's Phone Number *

Owner's Date of Birth (Month/Day/Year) *

*The United States Drug Enforcement Administration (DEA) requires the Date of Birth of pet owners in order to receive dispensed medications for their pets.

Primary Owner's First Name *

Primary Owner's Last Name *

Home Address *

Apartment #, Suite #, etc.

City *

State/Province *

ZIP / Postal Code *

Primary Owner's Email Address *

Primary Owner's Phone Number *

Primary Owner's Date of Birth (Month/Day/Year) *

*The United States Drug Enforcement Administration (DEA) requires the Date of Birth of pet owners in order to receive dispensed medications for their pets.

Secondary Owner

Secondary Owner's First Name *

Secondary Owner's Last Name *

Home Address *

Apartment #, Suite #, etc.

City *

State/Province *

ZIP / Postal Code *

Secondary Owner's Email Address *

Secondary Owner's Phone Number *

Secondary Owner's Date of Birth (Month/Day/Year) *

*The United States Drug Enforcement Administration (DEA) requires the Date of Birth of pet owners in order to receive dispensed medications for their pets.

Emergency Contact

Emergency Contact's First Name *

Emergency Contact's Last Name *

Emergency Contact's Phone Number *

Do you authorize your Emergency Contact to make medical and/or financial decisions for your pet? *YesNo

PET INFORMATION

How many pets are you bringing in for this visit? *123

Pet's Name *

Pet's Breed *

Pet's Species *

Pet's Color

Pet's Gender *

Pet's Reproductive Status *

Pet's Date of Birth (Month/Day/Year)

If Pet's Date of Birth is not known, please leave this field blank and fill in the Approximate Age field below.

Pet's Approximate AgePlease fill in Pet's Approximate Age in Years, Months, or Weeks.

1st Pet

1st Pet's Name *

1st Pet's Breed *

1st Pet's Species *

1st Pet's Color

1st Pet's Gender *

1st Pet's Reproductive Status *

1st Pet's Date of Birth (Month/Day/Year)

If Pet's Date of Birth is not known, please leave this field blank and fill in the Approximate Age field below.

1st Pet's Approximate AgePlease fill in Pet's Approximate Age in Years, Months, or Weeks.

2nd Pet

2nd Pet's Name *

2nd Pet's Breed *

2nd Pet's Species *

2nd Pet's Color

2nd Pet's Gender *

2nd Pet's Reproductive Status *

2nd Pet's Date of Birth (Month/Day/Year)

If Pet's Date of Birth is not known, please leave this field blank and fill in the Approximate Age field below.

2nd Pet's Approximate AgePlease fill in Pet's Approximate Age in Years, Months, or Weeks.

3rd Pet

3rd Pet's Name *

3rd Pet's Breed *

3rd Pet's Species *

3rd Pet's Color

3rd Pet's Gender *

3rd Pet's Reproductive Status *

3rd Pet's Date of Birth (Month/Day/Year)

If Pet's Date of Birth is not known, please leave this field blank and fill in the Approximate Age field below.

3rd Pet's Approximate AgePlease fill in Pet's Approximate Age in Years, Months, or Weeks.

Medical Consent

By placing your signature in the box below, I, the owner of the aforementioned pet, hereby authorize the veterinarian at Aspire Veterinary Center to diagnose, prescribe medications (understanding that some medications will be used off-label), perform therapeutic procedures and/or surgery which the veterinarian may dictate to be advisable for the well-being of my pet. I also understand that there is no warranty or guarantee that has been made to the result or cure. I further understand that I will be given an estimate to sign prior to services rendered and that once the estimate is signed I am financially responsible for the authorized services that were performed. *

Please sign here if you agree to Aspire Veterinary Center's Medical Consent Policy.

Media Consent

By placing your signature in the box below, I, the owner of the aforementioned pet, hereby grant permission to Aspire Veterinary Center to use my pet's name and likeness, either from photographs and/or video taken of me and my pet, in all its publications, including website entries, without payment or any other considerations. I further authorize Aspire Veterinary Center to edit, alter, copy, exhibit, publish or distribute photographs and videos for the purpose of publicizing promotional materials including but not limited to advertisements, brochures, newsletters, flyers, posters, and submissions to social media networking sites and other print and digital communications or for any other lawful purposes. In addition, I waive any right to royalties or other compensation arising or related to the use of the photographs and/or videos. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization.

Please sign here if you agree to Aspire Veterinary Center's Media Consent Policy.

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