Client Information Form

Thank you for choosing Companion Care Veterinary Hospital & Urgent Care! To start your pet care journey with us, please complete our required client information form online.

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Prepare for your pet’s first appointment with us by filling out this form as completely and accurately as possible!

First, let's cover the basics!

Owner's Name *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address

Same as home address

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Number *

Work Number

Employer

Email *

Owner's Date of Birth *

(req. controlled substances)

Co-Owner Information (if applicable)

Co-Owner's Name

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address

Same as home address

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Number

Work Number

Employer

Emergency Contact Information

Emergency Contact *

Phone Number *

Does this person have authorization to make medical decisions? *

Almost done!

I hereby authorize the Veterinarian to examine, prescribe for, and/or treat my pet(s). I assume responsibility for all charges incurred in the care of my animal(s). I understand payment is due when services are rendered. In the event my account becomes delinquent, I understand I am responsible to pay actual and reasonable fees for service and collection charges and/or attorney fees together with interest of 1.5 percent per month.

Signature *

Clear Signature

Date *

Referred by:

Friend
Website
Saw a sign
Other

Client Information Form

Start here.

First, let's cover the basics!

Co-Owner Information (if applicable)

Emergency Contact Information

Almost done!

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