Client Information Form in Garden Grove & Fullerton, CA | Emergency Veterinarian and Animal Hospital in Garden Grove, CA

Date*

Date Format: MM slash DD slash YYYY

Have you been here before?*

Yes
No

If so, when?

Your Last Name*

Your First Name*

Name of Spouse or Co-Owner

First Last

Address*

Street Address Apartment or space number City State ZIP Code

(PO Box is not allowed)

Your primary phone number*

Your secondary phone number

Do you have an email?*

Yes
No

Your email address*

How did you choose our clinic? (Referral Source)*

Pet's Name*

Species*

Breed*

Sex*

Color*

Birthdate (approximate age is okay)*

Who is your pet’s family veterinarian or veterinary hospital?*

What is the reason for your visit today?*

Please describe any pre-existing medical conditions or drug allergies for your pet

Important Information - Please Initial

I certify that I am 18 years of age or older.*

Initial Here

I certify that I am the owner of the animal described here.*

Initial Here

I authorize the Orange County Emergency Pet Clinic (OCEPC) to treat the animal described here and that this may include diagnostics, an anesthetic and/or surgery.*

Initial Here

I understand that no guarantee of successful treatment is made, and that I will not hold the Orange County Emergency Pet Clinic responsible for my animal’s recovery.*

Initial Here

I understand that all treatments and medications are in addition to the emergency examination fee and agree to pay all the charges incurred.*

Initial Here

I understand that payment is expected at time of service. Payment plans are not offered, except through CareCredit and Scratchpay, which require a credit check and approval by a third party.*

Initial Here

I understand that Orange County Emergency Pet Clinic is not open 24 hours per day. All patients must be discharged before closing each day at 8:00AM (except Sundays and Holidays). If my pet requires further care, I understand that I will need to transfer my pet to my family veterinarian for continued care.*

Initial Here

I understand that if I do not pick up my pet at the time required, Sec. 1834.5 of the CA Civil Code shall deem my pet abandoned and I may incur additional fees and incur criminal charges.*

Initial Here

I authorize photos to be taken of my pet to be used for educational and marketing purposes.*

Initial Here

Thank you for completing this electronic form. Our staff will print this out and have you sign the following in person:

I have reviewed the information above and find it to be correct. I agree to the statements above.

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Please Print Your Name

________________________________
Please Sign Your Name

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Today’s Date