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Client Information

Client's Name*

First Last

Date Today*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Landline Number

Mobile Number

Email Address*

Pet Information

List of all Pet Information

Name

Species

Breed

Sex

Birthdate

AUTHORIZED CONTACTS

List name(s) and each item they are allowed to authorize for your pet(s):

Name

Medical Treatment (Y/N)

Surgery/Dental (Y/N)

Euthanasia (Y/N)

Pet Pickup (Y/N)

Food/Med Pickup (Y/N)

On occasion, CAMC doctors and staff take digital photographs, radiographs and ultrasound images of patients for medical, continuing education, promotional and entertainment purposes. I give permission for my pet's digital images to be shared as follows: (Please check all that apply)*

None

CAMC Website

Referral Doctors

Social Media

Printed Literature

Please list preferred CAMC doctors:

Please list any previous veterinary clinics(if any) that have been visited for your pets listed above:

Please list any pet insurance companies in use(if any) for pets listed above:

Please select preferred contact method for non-emergency use:

Phone Call

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GENERAL POLICIES - Please initial each policy below:

I understand that CAMC is not staffed 24 hours per day. I acknowledge that the normal operating hours for CAMC are: Mon - Fri 7:30 am - 7 pm, Sat-Sun 9am - 5 pm (closed some holidays). CAMC kennel team members usually arrive at 7:30 am and leave at 7 pm.*

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Boarding is charged on a 24 hour basis. If you drop off at 11 am, your check out time is 11 am. If you arrive for check out after that time, you will be charged another day.*

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I understand that CAMC offers and sells Premier Pet Club Memberships which give a pet unlimited free medical exams and a 10% discount on products and services for the period of one year from the date of payment of the PPC membership fee. I understand that this plan is for one pet, is non-refundable and is non-transferrable. I acknowledge that this plan is not insurance, and it does not include preferential appointment scheduling or boarding reservations. CAMC will offer the same boarding reservations and medical appointments for pets regardless of PPC membership status.*

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I understand that all sales at CAMC, including medications, are final except for Hills and Royal Canin prescription foods. Prescription foods may be returned for CAMC credit, but not for a refund.*

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I understand that payment for all products and services is expected when my pet leaves CAMC (on occasion, CAMC may require a deposit for complicated cases). CAMC accepts cash, Zelle, debit , credit cards or Care Credit. CAMC does not accept checks for payment.*

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Any price you were quoted is a cash or Zelle price (we do not accept checks). If you choose to use a credit/debit card, the credit card processing company will charge a 2.79% admin fee.*

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I understand that in order to enhance customer service and/or record keeping, CAMC may utilize a digital scribe during my visit.*

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By signing this form, you have read and understand all of these policies, and you agree to abide by them.*

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Client's Name*

First Last

Date*

Signature*

Client Information Form

Client Information

Pet Information

AUTHORIZED CONTACTS

GENERAL POLICIES - Please initial each policy below:

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