"*" indicates required fields Name* First Last Co-owner Name First Last Primary Phone Number*Secondary Phone numberCo-owner PhoneAddress* Street Address City State / Province / Region ZIP / Postal Code Email* Date of Appointment* MM slash DD slash YYYY Place of Employment Drivers License#* Emergency contact name and phone number:Whom may we thank for referring you?* How did you hear about us?* First Animal’s Name:* Date of Birth/Age* Species* Canine Feline Hamster Guinea Pig Bird Rabbit Reptile Other Breed:* Gender:* Male Female Spayed./Neutered?* Yes No Color:* Approximate date and type of last exam and vaccines:*Previous health conditions/concerns:*Reason for visit today:*Any Previous Records Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB. Second Animal’s Name: Date of Birth/Age Species Canine Feline Hamster Guinea Pig Bird Rabbit Reptile Other Breed: Gender: Male Female Spayed./Neutered? Yes No Color: Approximate date and type of last exam and vaccines:Previous health conditions/concerns:Reason for visit today:Any Previous Records Drop files here or Select files Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 256 MB. Communication Consent FormWe at Jefferson Animal Clinic consider you and your pet(s) as part of our family. During the year, we would like your permission to communicate with you regarding things that can be of assistance to you and your beloved pet(s). We regularly send out e-newsletters with helpful tips for the health care of your pet(s) and would love to have you follow us on Facebook and Instagram! We also want to be able to send a “thank you” for any referral you might give, a best wish for a Birthday or holiday, special offers on health care products that we recommend and of course, reminders for upcoming appointments. By receiving your permission, we know that we are communicating with you because you want to receive information that will benefit the health and well-being of your pet(s). Please check (X) below to tell us which way you are willing to be communicated with:Preferred method of contact* Direct Mail other than “Reminders” (post office) Phone other than “Reminders” Text Email PhoneEmail We respect your privacy and will not sell, rent or trade any of your personally identifiable information. The above are for communications from our hospital to you, and will not be used for any other reason.Thank you for being a part of our family! We truly care about you and your pet(s) and look forward to communicating with you throughout the year! Release of Information for Media or Website Publication Here at Jefferson Animal Clinic, we like to educate our clients, share interesting cases, facts and tips about caring for your pet(s)! We also love to take pictures and videos to share with everyone on social media and newsletter publications. No personal or sensitive information is ever used. Only the pet’s name and information regarding the services provided may be used at any time. I hereby give permission to Jefferson Animal Clinic to use my pet’s photo and I expect no remuneration. I understand these photos and videos may be altered and used in various print media for the benefit of the practice and pet owners like me. My permission will be in effect until I request, in writing, to have my photos removed from the practice’s archive. Please make your selection and sign the release form below.* YES I give permission to Jefferson Animal Clinic to use my pet’s photos NO I do not give permission to Jefferson Animal Clinic to use my pet’s photos Signature (or printed name) of Owner or Authorized Agent*CommentsThis field is for validation purposes and should be left unchanged.
