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Client Intake Form

Welcome and thank you for choosing RMSAH for your pet’s care. Please complete the following information about you and your pet.

About you:

Client name:

Street Address:

Apt/Unit#:

City:

State:

Zip:

Email address:

Phone: (cell)

(home)

Spouse/Partner name:

Phone:

Preferred method of contact: (please select one)

Contact Choice

Phone

Text

How did you hear about our hospital? Website

Hear About choice

Client

Other

Other Choice

About your pets:

Name:

Sex:

Male

Female

Spayed or Neutered:

Yes

DOB:

MM slash DD slash YYYY

Species:

Cat

Dog

Other

Other Details

Date of last Rabies vaccine:

MM slash DD slash YYYY

Previous Vet:

Would you like to add a second pet?

Yes

Name:

Sex:

Male

Female

Spayed or Neutered:

Yes

DOB:

MM slash DD slash YYYY

Species:

Cat

Dog

Other

Second Pet Other

Date of last Rabies vaccine:

MM slash DD slash YYYY

Previous Vet:

Would you like to add a third pet?

Yes

Name:

Sex:

Male

Female

Spayed or Neutered:

Yes

DOB:

MM slash DD slash YYYY

Species:

Cat

Dog

Other

Third Pet Details

Date of last Rabies vaccine:

MM slash DD slash YYYY

Previous Vet:

I hereby authorize Rocky Mountain Small Animal Hospital to examine, prescribe for and treat the above described pet(s). I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment. I understand that once I leave the facility with a prescription it can no longer be refunded due to possible tampering and legal concern

I have read and understand

Client Signature

Signature:

Date:

MM slash DD slash YYYY

Pet Photo Release

Client Name:

Pet’s Name:

Date:

MM slash DD slash YYYY

We love sharing photos of our furry patients to showcase the special moments at HOSPITAL. We occasionally take photos of pets during visits, events, or while on our property. With your permission, we would like to use these photos for marketing, social media, and other promotional purposes.

hereby grant HOSPITAL the irrevocable right and permission to use photographs of my pet(s) taken during their visit, on our property, or at any event hosted by HOSPITAL.

This permission includes, but is not limited to, the use of the photographs in promotional materials, social media, our website, and other forms of public display.

I understand that I will not receive any compensation for the use of these images, and I waive any rights to royalties or other compensation for the use of these photographs.

I also understand that these images may be used in perpetuity and may be edited, altered, or modified as needed for the intended purpose.

I confirm that I am the legal owner of the pet(s) listed above and have the authority to grant this permission.

Please select one:(Required)

I agree to the terms above and allow HOSPITAL to use photos of my pet(s).

I do not agree to the terms above and do not want photos of my pet(s) used.

Signature:

Date:

MM slash DD slash YYYY