New Client Information Form

Client's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Date of Birth *

Due to C.U.R.E.S., (Controlled Substance Utilization Review and Evaluation System), the Cardiff Animal Hospital & Wellness Center must report all controlled drugs sent home with clients. To provide the correct information to C.U.R.E.S., we must have your date of birth.

Employer *

Work Phone

Spouse/Co-Owner's Name

First

Last

Spouse/Co-Owner's Phone

Preferred method of contact for appointment and patient reminders *

Call
Text
Email

By checking the option to receive text messages from the Cardiff Animal Hospital & Wellness Center at the mobile number provided, you understand that stan- dard text messaging fees or data rates may apply. You also understand that you have the option to opt out of this service at any time.

Who may we thank for referring you to our hospital?

Pet Information

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Any known allergies/vaccine reactions? *

Current medical conditions, ongoing treatments, or previous pertinent medical conditions or illnesses *

Photo Release

Do you authorize Cardiff Animal Hospital & Wellness Center the right to take photographs of my pet, and to copyright, use, and publish the same in print and/or electronically. This could include, for example, such purposes as publicity on Facebook, illustration in newsletters, and on the Cardiff Animal Hospital & Wellness hospital website. *

I authorize
The Cardiff Animal Hospital & Wellness Center DOES NOT have the right to take photographs of my pet, and use or publish the same in print and/or electronically.

Payment & Fee Schedule

Payment for all services is due at the time services are rendered. At your request, we will gladly discuss the cost of all services and/or prepare a written estimate of costs for the recommended treatment(s) or services. A deposit for services is required for all pets being admitted to the hospital. We accept cash, Visa, Mastercard, Discover, and Care Credit. We apologize in advance, but we DO NOT accept American Express or checks.

Signature *

Clear Signature

Date *

Complete This Form Before Your Next Visit

Pet Information

Photo Release

Payment & Fee Schedule