Client Information Form

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Client Information Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Information Copy

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Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone *

Cell Phone *

Email *

Social Security *

Driver’s license # (if paying by check)

How did you find out about us?

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Whom may we thank for referring you:

Authorization for Treatment and Financial Policy

I am 18 years of age or older and authorize the veterinarians and staff of Gem Veterinary Clinic to examine my pet and administer treatment as is considered necessary for my pet’s condition. An estimate will be prepared upon request. In emergency or life threatening situations I authorize stabilizing care upon arrival but no invasive or diagnostic treatment will be undertaken unless discussed with me. I understand that Gem Veterinary Clinic may refuse services for any reason. I release Gem Veterinary Clinic of all liability in the event of injury, bite, fall or other circumstance that might cause injury while I/my family members am/are a visitor or patron at the clinic. I assume all risks and will take precautions regarding my and my family’s safety.

I agree to pay for all services rendered on behalf of my pet at the time of discharge
We accept cash, check, Visa, MasterCard, and CareCredit.

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Signature *

Date *

Client Information Form

Client Information Form

Client Information Copy

Authorization for Treatment and Financial Policy

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