Portsmouth Veterinary Clinic New Client Form
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2Portsmouth Veterinary Clinic New Client Form
Last Name: ________________________________
First Name: ________________________________
Partner Last Name: _________________________
Partner First Name: __________________________
Address: __________________________________
E-Mail: ____________________________________
City, State, Zip: _____________________________
Home #: __________________________________
Work #: ___________________________________
Partner Work #: ____________________________
Cell #: ____________________________________
Partner Cell #: ______________________________
Social Security #: ____________________________
Partner Social Security #: _____________________
Required for writing checks
License #: __________________________________
Date of Birth: _______________________________
Required for writing checks
Emergency Contact:___________________________________________________________________________
Preferred method of payment: _________________________ (Visa, MC, Discover, Am. Ex, Check, Cash)
How did you become aware of our hospital?
Yellow Pages
Hospital Sign
Other
Personal recommendation - whom may we thank?
_________________________________________
In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Portsmouth Veterinary
as deemed necessary.
It is understood that an estimate of charges will be given for services. Further, I realize that this is an estimate and
there may be additional fees due to unforseen changes in the treatment plan. I understand that I will be contacted,
if possible, if there are any changes needed.
I authorize the use of photographs of my pet(s) for identi cation and for any use and publication, without my name,
for any lawful purpose, including publicity, illustration, adverstising, social media and web content. You may use
my pet(s) name if you use any photographs of my pet(s).
Payment is due when services are rendered.
Client Signature: ____________________________________________________
Date: ______________
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