Client Information Form Welcome to Milford Veterinary Hospital. It is our mission to provide the best possible health care for your pet(s). With compassionate and thorough medical, surgical and dental practices we strive to always exceed our clients' and patients' needs.PRIMARY OWNERS*(Authorized to change/add/remove information on the account and release medical records to a third party.) 1. First Name 1. Last Name PRIMARY OWNER CONTACT INFO* Mailing Address Physical Address (if different): Primary Phone:*Indicate:HomeCellWorkSecondary Phone:Indicate:HomeCellWorkEmail Address:* SECONDARY OWNER CONTACT INFO* 2. First Name 2. Last Name Secondary Owner Address* Mailing Address Physical Address (if different): Primary Phone:*Indicate:HomeCellWorkSecondary Phone:Indicate:HomeCellWorkEmail Address:* Other persons authorized to make medical and/or financial decisions concerning your pet(s).Preferred contact method?*EmailPhoneWho is YOUR personal emergency contact?NamePhoneEnter their phone #:Is there anyone in your home with a peanut allergy?YesNoIf yes, who?If you were referred to our practice, whom may we thank?SERVICE AGREEMENT - ALL PROFESSIONAL FEES ARE DUE WHEN SERVICES ARE RENDERED* I agree that my failure to pay Milford Veterinary Hospital constitutes a material ‘breach’ of this agreement. I will be in default of this agreement if I fail to make a payment in full when it becomes due. I further agree that if I am in default, I will pay all cost of collection, including reasonable attorney fees.PHOTOGRAPHY/VIDEOGRAPHY AUTHORIZATIONPART ONE:* I authorize Milford Veterinary Hospital to take photographs and/or videos of my pet(s), to edit/alter and publish those photographs/videos, along with my pet’s name, for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials and waive any rights of privacy or compensation associated with said photographs/videos. I DO NOT authorize the above.PART TWO:* I authorize the same as above for photographs and/or videos taken by Milford Veterinary Hospital that include myself. I DO NOT authorize the above.By signing below, you are confirming that the above information is up to date, complete and accurate.Signature*Date* Date Format: MM slash DD slash YYYY
