Client Intake Form Owner's Full Name*Owner's DOB* MM slash DD slash YYYY Owner's DL#Secondary Owner:Current Mailing Address Street Address City State / Province / Region ZIP / Postal Code Phone NumberNamePhone Number Email If a current client referred you, please let us know so we can thanks them!CLIENT NOTICEAll professional fees are to be paid AT THE TIME SERVICES ARE RENDERED. A written estimate may be provided at your request ALL MISSED DOCTORS APPOINTMENTS WILL INCUR A $45 FEE. ALL MISSED TECHNICIANS APPOINTMENTS WILL INCUR A $ 25 FEE. WE ALSO ARE IMPLEMENTING A LATE POLICY WHERE WE CAN'T GUARANTEE SEEING THE PET PAST 5 MINUTES OF THE SCHEDULED APPOINTMENT TIME.SignatureDate MM slash DD slash YYYY Please initial to authorize the release of medical records to any person not on record.(i.e: groomer, other hospitals, etc.) If you are not the pets owner please fill out the portion below: I AM AWARE THAT I AM FINANCIALLY RESPONSIBLE FOR TODAY'S VISIT. MPH IS NOT RESPONSIBLE FOR ARRANGING 3rd PARTY PAYMENTS.Full NameRelationship to owner:AddressPhoneSignatureDate MM slash DD slash YYYY
