Annual Client Registration & Consent Form

For accurate communication we need to keep all your information current. Please fill out our annual form so can make sure your record is updated.

Owner/Agent Name*
First Last
Phone*
Spouse / Co-Owner*
First Last
Phone*
Which Number is Primary?*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
1) Photo Consent:
We LOVE social Media! Do we have your permission to share your pet(s) image/video/story on social media, our website & other forms of related media? *Your name and personal information will never be shared*
Simply check to authorize*
- YES! Please share
- NO. I do not authorize this
2) Treatment Consent:*
- I do
Upon signing this agreement, I certify I am the Owner/Authorized Agent of above pet(s) and have authorization to consent to treatment if and when needed. I authorize AVH to examine, prescribe for and/or treat the above pets. I recognize that financial concerns should be discussed PRIOR to exam & treatment.

I understand I am entitled to ask for and be provided with a written estimate of fees regarding services and/or products prior to services being performed. I assume full responsibility for all charges incurred and understand these incurred charges are to be paid, IN FULL, at the time the services are rendered. (Accepted payment methods: Cash, Credit Card (Visa, Mastercard, Discover, American Express), Check (DL # required) and Care Credit.)
Signature
Date
MM
DD
YYYY