Updated Client & Pet Information Form

Client Information

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number

Cell Phone Number

Secondary Contact Name

Secondary Contact Phone Number

Current Pet Information

Please provide the following information for ALL pets currently in your household:

Pet Information

Pet Name	Age/DOB	Species	Breed	Color	Sex	Spayed / Neutered

Please list any deceased pets or pets no longer in your home

I grant Flint Veterinary Care Center permission to post my pet’s picture, story, history on social media:

Authorization

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for charges incurred in the care of this animal. I understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. I understand there will be a $50 fee for any returned checks. I am also aware that I need to call 24 hours in advance of an appointment if said appointment needs to be canceled or rescheduled. Missed appointments will result in the following fees: $65 for a missed doctor appointment; $28 for a missed technician appointment, and $150 for missed a surgery appointment.

Signature

Sign Here

Signature Date