Client Information Form

Client Information Form

I affirm that I have read and understand the following: – I, the owner or the agent for the owner of this animal (or these animals) authorize the veterinarians and staff of Farnam Pet Hospital to perform the recommended procedure(s) and use all related medications, tests, and treatments. – I understand payment is due at the time of service. I may request an estimate before treatments are performed if desired. – I understand the risks related to immunization and the signs of an allergic reaction that would require emergency medical treatment have been explained to me. – I understand the CDC’s recommendation on strategic deworming and parasite prevention. – I understand that all payment is due the day services are rendered. Interest on accounts unpaid for more than 30 days will be charged at a rate of 1.5% per month, which equals 18% per year. – By checking "I give my consent" above and submitting this form and waiver, I give Farnam Pet Hospital the right to use my pet’s picture and information that I provide to the hospital (via story for Facebook, blog or newsletter, or via testimonial) for reproduction in any medium including but not limited to: website, video, broadcast, print, and electronic means for purposes of advertising, trade, display, exhibition or editorial use. Further, I also (i) agree to release Farnam Pet Hospital from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity or any other claim and (ii) confirm that I am over the age of 18 years old.