Client Contact Information Client Contact Information Primary Owner Information Name * Name First Name First Name Last Name Last Name Primary Phone * Alternate Phone Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Preferred Contact Method * Call Text Email Secondary Contact / Authorized Personnel (this person may make medical or financial decisions for your pet if you are unavailable) Name * Name First Name First Name Last Name Last Name Relationship to Owner * Phone * Email Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Authorized for: * Drop-off/Pick-up pet Approve treatment plans Make payments Access medical records (check all that apply) Emergency Contact (If Different from Above) Name Name First Name First Name Last Name Last Name Phone Consent Agreement At Lincolnway Veterinary Clinic, we love celebrating our patients and sharing special moments from our practice with our community! With your permission, we may post photos, videos, or stories featuring your pet on our social media platforms, website, or other marketing materials. Please review and indicate your preferences below: Photo / Social Media Release * I GIVE CONSENT for Lincolnway Veterinary Clinic to use my pet’s name, image, and likeness in photos, videos, or other media for the purposes of social media, advertising, and promotional content. I DO NOT GIVE CONSENT for Lincolnway Veterinary Clinic to use my pet’s name, image, or likeness for any public or promotional purposes. Financial Policy and Payment Authorization I understand that payment is due in full at the time services are rendered. Lincolnway Veterinary Clinic accepts cash, debit, credit cards, Care credit or other approved payment methods.I understand that I am financially responsible for all charges incurred for my pet’s care, including services authorized by my designated secondary contact. * I understand and agree Lincolnway Veterinary Clinic has a No Call, No Show/Cancellation Policy that is as follows - We require 24 hours' notice for any canceled appointments. Due to the number of patients we are serving, our appointment times are very valuable. If you are unable to make your appointment and do not give us proper notice, a fee equivalent to the price of the exam will be assessed on the account and must be paid before we can reschedule. * I understand and agree Veterinary & Care Authorization I hereby authorize Lincolnway Vet Clinic, its veterinarians, and staff to examine, diagnose, and treat my pet as deemed necessary. I understand that I will be informed of the recommended treatment plan and estimated costs prior to services being performed. * I authorize Signature signature keyboard Clear Date Captcha Submit If you are human, leave this field blank.
