Home Annual Client Registration & Consent Form

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 / Province / Region

ZIP / Postal Code

Country
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:
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

Month

Day

Year
CAPTCHA

1) Photo Consent: