New Client/Yearly Record Update Form

2024 Client Record Update
Name*
First and last name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Home
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
E mail Address
[email protected]
Do you wish to receive email reminders?

YesNo
Employer's Name and Address
Spouse/Authorized Agent
First and last name
Spouse/Authorized Agent Phone
Please enter a valid phone number.

Please list ALL the pets you currently own in the form below.If more animals are owned than the space provided please fill out records in the office.

	Pets Name	Dog or Cat	Breed	Color	Age or Birth Date	Male or Female	Spayed or Neutered
1
2
3
4
5
6
7
8
9

Authorization:
- I authorize the doctors and staff of Easiview Animal Hospital to treat my pet. I understand that there are risks and side effects associated with medical care and treatment. I understand that the doctors and staff of Eastview Animal Hospital are not able to inform me of all the possible risks and side effects, known and unknown, associated with medical treatments. I understand that I will be informed of the more common risks and side effects based on the most recent information available to them. I understand that information may be in the form of verbal or written communication including but not limited to: phone calls, in person conversations, emails, or informational handouts. I understand that the staff will make a reasonable effort to address my concerns prior to or after any medical treatment. I understand that I have the right to deny or decline any medical treatment for my pet.
- I understand that my pet must have a current rabies vaccine as required by Iowa State Law and must be administered in accordance with the law in order for my pet to be a patient at Eastview Animal Hospital.
- I give my consent for Easiview Animal Hospital to release my pet's medical records when requested by myself, other authorized parties, or another veterinary facility.
I acknowledge that I am the owner and/or authorized agent and am over the age of 18. I have read and understand the above policies. I understand that Eastview Animal Hospital and their staff will be held harmless from decisions that I make on behalf of my pet that are against medical recommendations including but not limited to: declining of vaccinations, diagnostic testing, medications and purchases of medication through sources other than Eastview Animal Hospital or the online pharmacy, MyVetStoreOnline.
Signature of Owner*

Clear
Date*

MonthDayYear
Date
Full payment is expected when services are rendered We do not carry open balances. We accept the following forms of payments: Cash, Check, Visa, Mastercard, Discover, Amex or Care Credit. There will be a return check fee for any returned checks #f a balance is unpaid charges will incur a 1.5% monthly finance charge. A deposit may be required for emergencies, surgical procedures, hospitalizations and new clients. Please read and sign other side
Please select one option and initial next to it: Permission to use pet's photograph or video.
I hereby give my consent for Eastview Animal Hospital to take photographs or video of my pet which may be broadcast, print and social media. I understand there will be NO compensation from Eastview Animal Hospital use of the photograph(s) now and in the future. I will make no monetary or other claim against Eastview Animal Hospital for the use of the photograph(s).
I decline Eastview Animal Hospital posting pictures of my pet on any of their print, social media, website or any broadcast.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Online Forms

2024 Client Record Update