Client Information Form Date* Date Format: MM slash DD slash YYYY Have you been here before?*YesNoIf so, when?Your Last Name*Your First Name*Name of Spouse or Co-Owner First Last Address* Street Address Apartment or space number City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (PO Box is not allowed)Your primary phone number*Your secondary phone numberDo you have an email?*YesNoYour email address* How did you choose our clinic? (Referral Source)*Referred by my family veterinarianReferred by a one of our clientsGoogleYelpFacebookOur WebsiteSaw our sign or buildingBeen here beforePet's Name*Species*DogCatRabbitBirdFerretRodentReptileBreed*Sex*MaleMale, NeuteredFemaleFemale, SpayedUnknownColor*Birthdate (approximate age is okay)* Date Format: MM slash DD slash YYYY 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 petImportant Information - Please InitialI certify that I am 18 years of age or older.*Initial HereI certify that I am the owner of the animal described here.*Initial HereI 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 HereI 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 HereI understand that all treatments and medications are in addition to the emergency examination fee and agree to pay all the charges incurred.*Initial HereI 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 HereI 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 HereI 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 HereI authorize photos to be taken of my pet to be used for educational and marketing purposes.*Initial HereThank 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.________________________________ Please Print Your Name________________________________ Please Sign Your Name________________________________ Today’s Date