New Client Form Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following. Client informationYour Name* First Middle Last Your Date of Birth* MM slash DD slash YYYY Spouse's Name Spouse's Date of Birth MM slash DD slash YYYY Referred By Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Employer Work Phone*Driver's License # Email* Pet InformationName* Breed* Color* Age/Date of Birth* Previous Vet* Sex* Female Male Spayed Female Neutered Male Type* Canine Feline Add Another Pet I have another pet to add Name* Breed* Color* Age/Date of Birth* Previous Vet* Sex* Female Male Spayed Female Neutered Male Type* Canine Feline Add Another Pet I have another pet to add Name* Breed* Color* Age/Date of Birth* Previous Vet* Sex* Female Male Spayed Female Neutered Male Type* Canine Feline Payment is expected in full at the time of service. Cash accounts enable us to operate more economically, thus reducing your cost of treatment. A deposit will be required when emergency services or extensive medical treatments are performed. A 1.5% service fee will be charged on all unpaid monthly balances. Photos may be taken of your pet for identification purposes and kept on record for reference. Often, we need reference photos and we prefer to draw from our patient base. These photos may be used on our social media platforms to depict a certain breed or just for a fun reference. We will never release these photos for use outside of our practice. The following will grant us permission to photograph your pet(s) without obligation of financial reimbursement.* Yes. I grant to Cole Veterinary Hospital, its representatives and employees the right to take photographs of my pet(s) in connection with the above- identified subject, I authorize Cole Veterinary Hospital, its assigns and transferees to copyright, use and publish the same in print and/or electronically, I agree that Cole Veterinary Hospital may use such photographs of my pet(s) without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content. No. I decline to have Cole Veterinary Hospital use or publish photographs of my pet(s) for any reason.