Client Information Form Welcome to Greenbrier Emergency Animal Hospital. Our staff is dedicated to the optimum in patient care and will do its utmost to make your pet's stay pleasant and beneficial. Please feel free to ask any questions concerning the treatment of your pet or other policies of the clinic. To help us serve you better, please provide us with the following information.First Name:Last Name:Spouse's First Name:Spouse's Last Name:Address:Address Line 2:City:State:Zip Code:Preferred Phone*Home Phone:Cell Phone:Work Phone:Spouse's Cell Phone:Place of Employment:Spouse's Place of Employment:Driver's License #:Email How did you choose our practice? Online Search Existing Client Referral Email Print Ad Social Media Online Reviews Word of Mouth Phonebook Regular Veterinarian Location Other If Relative/Friend or Other, please specify:Name of your Regular Veterinary Hospital:Who is your Regular Veterinarian?Is your pet under the care of a Veterinary Specialist? If yes, who should we send a copy of the medical records to (Cardiology, Oncology, Surgery)?Patient InformationPet's Name:Species and Breed:Age:Color:Sex: Female Spayed Male Neutered Date of Vaccinations for DogsRabies:DHLP:Parvo:Corona:Lyme:Heartworm Prev.:Date of Vaccinations for CatsRabies:FIP Vaccination:Leukemia:FVRCP (distemper):Heartworm Prev.:Authorization & Digital Communication Consent I authorize the hospital to release my pet’s medical information to other veterinary hospitals, groomers, and kennels, including my phone number if my lost pet is recovered. I acknowledge that conversations during my pet’s visit may be recorded for quality assurance and service improvement purposes. I hereby grant the hospital all rights, title, and interest in any photographs, images, videos, or audio recordings of my pet or myself taken during my pet’s visit. This includes the use of such materials for promotional purposes, on the hospital’s website, and other marketing materials. If the veterinary team determines that immediate treatment is necessary for the health and well-being of my pet, and I or my co-owner are unable to be reached, I consent to the administration of all reasonable treatments recommended. I assume responsibility for all charges incurred for my pet(s) and understand that payment is due at the time services are rendered. I understand that the hospital offers various forms of digital communication to keep me informed about my pet’s health, remind me of upcoming appointments, and share promotions and health tips. By signing below, I authorize the hospital to contact me via email, phone, and/or text message (SMS). I understand that I can opt out of these communications at any time by following the unsubscribe instructions in any communication received. Δ
