New Client Form | Mercy Pet Hospital Citrus Heights & Fair Oaks

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Email(Required)

Your e-mail address will be kept private and only used by Mercy Pet Hospital, Inc. for the purposes of communication and notifications.

How did you first hear of us?(Required)

Authorized Person on Account (must be 18 years of age)

Name

First Last

Relationship

Primary Phone

Secondary Phone

I authorize Mercy Pet Hospital, Inc. to publish the photographs taken of me and/or my pet for use in printed publications and websites. I acknowledge that since my participation in publications and websites produced by Mercy Pet Hospital is voluntary, I will receive no financial compensation. I further agree that my participation in any publication and website produced by Mercy Pet Hospital, Inc. confers upon me no rights of ownership whatsoever. I release Mercy Pet Hospital, Inc., their contractors and its employees from liability for any claims by me of any third party in connection to my participation.

Yes

Initial:(Required)

Patient Information

Pet's Name(Required)

Date

Species(Required)

Breed(Required)

Color(Required)

Microchipped(Required)

Yes

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

I, the undersigned owner of the above admitted patient, hereby authorize the doctors and staff of Mercy Pet Hospital, Inc. to administer such treatments as is necessary and to perform procedures therapeutically and/or diagnostically. I understand that no guarantee of successful treatment is made. I further understand that this facility does not operate on a 24 hour basis, therefore, there is no continuous presence of personnel after regular business hours. I certify that all of the information above is correct; that I am the rightful owner of this pet(s); that I am at least 18 years of age; I assume full financial responsibility for all charges incurred and agree to pay all such charges at the time of services. Mercy Pet Hospital is a General Practice and while we make every effort to see every patient that walks through our doors, we may refer any potential emergency case to a veterinary emergency hospital.(Required)

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