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Client First Name

Last Name

Spouse/Secondary Owner

Address

City

State

Zip

Primary Phone

Secondary Owner Phone

Email

Patient Information

Patient Name

DOB/Age

Breed

Species

Canine
Feline

Color

Sex

Male
Female
Unknown

Altered

Spayed
Neutered
Unknown

Previous Veterinarian

Previous Vet Phone

I authorize the release of my pet’s medical records to Crestview Veterinary Clinic

Social Media Consent

Do you consent to photos taken of your pet?

We attach photos to our patient profiles to help us recognize your pets!

Yes
No photos of my pet

Do you consent to us posting photos of your pet? (TikTok, Facebook, Instagram, etc.)

If yes, social media is where we love showing off our patients and the great animal care we provide on sites such as TikTok, Facebook, Instagram, and others!

YES (you may post pictures of my pet)
NO (do not post pictures of my pet)

Date

note1

Payment is due as services are rendered. Payment is accepted in the form of debit or credit card only. **PLEASE NOTE - NO CASH ACCEPTED