Client Consent Form

Name: Veterinarian
Brand: Freeport Veterinary Hospital

Freeport Veterinary Hospital

"Fear Free Veterinary Medicine, tailored to you and your pet"

Client's Full Name:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Preferred Phone Number:

Email Address:

Co-Owners Name:

Co-Owners Phone Number:

How did you find out about our practice?

I authorize photos of my pet(s) to be included on the Freeport Veterinary Hospital's website, Facebook page and/or informational materials.

Yes

I hereby authorize the veterinarians to examine, prescribe for, or treat my pet(s). I assume responsibility for all charges incurred in the care of this (these) animal(s). I also understand that charges will be paid at the time services are rendered and that a deposit may be required for surgical treatment.

I have read and understand.

I am aware that my account is subject to a $51.05 charge for any appointments missed or cancelled with less than 24-hour notice. To be respectful of the medical needs of other patients, I will call promptly if I am unable to show up for an appointment at the schedule time.

I have read and understand.

Signature:

Sign above

Date:

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Client Consent Form

Review Us!

Get In Touch

Freeport Veterinary Hospital