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.SignatureReset signature Signature locked. Reset to sign again Date 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:AddressPhoneSignatureReset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
