New Client Form New Client Information Form Date * Prefix Owner's Name * Owner's Name First First Last Last Prefix Spouse/Other Name Spouse/Other Name First First Last Last 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 Home Phone Work Phone Cell Phone Spouse / Other Work Phone Spouse / Other Cell Phone Email * Occupation Employer How did you learn about our hospital? Drive-by Live Close Walk-in Previous Client Internet Client Referral (who can we thank?) Number of Dog in household? Number of Cats in household? Number of other pets (specify) in household? Reason for visit Pet Health History Pet's Name * Date of Birth or Close Approximation * Type of Animal * Dog Cat OtherOther Sex * Male Neutered Female Spayed Is your pet easily frightened to bite or claw? * No Yes, go slow! Breed * Color * Vaccination History (Last Date Given) Dogs Distemper Parvo Bordetella Rabies Dewormer This waiver covers all pets on your Sahara Pines Animal Hospital account Cats Distemper FELV Rabies Dewormer Name of previous hospital or clinic where vaccine and medical records can be researched * Phone Number of previous hospital or clinic where vaccine and medical records can be researched * Authorization I understand that I assume responsibility for all charges incurred in the care of my animal(s). I am aware that payment is due at the time services are rendered. Sahara Pines Animal Hospital does not provide any billing options (please ask about care credit payment plans). Payment may be accepted in the form of cash, personal local checks with a valid Nevada Driver’s License, Visa, Mastercard, Discover, American Express and Care Credit. * I agree How will you be paying for your visit? Cash Check (Nevada Driver's License required) Credit Card Care Credit I hereby certify that I am the owner, or duly authorized agent for the owner of the above described pet(s). I hereby authorize sahara pines animal hospital to examine, prescribe for, or treat these pet(s). Signature * signature keyboard Clear Today's Date * Media Release Form I grant permission to Sahara Pines Animal Hospital hereinafter known as the “SPAH” to use my pets image (photographs and/or video) for use in Media publications including Videos, Email Blasts, Facebook/Instagram/Tiktok, Newsletters, General Publications, Website and/or Affiliates, Other * I Authorize I DO NOT Authorize I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. * I Authorize I DO NOT Authorize I grant permission to SPAH to use Audio Recording within the hospital for the purpose of transcribing medical records I Authorize I Do Not Authorize Please select the option below which is applicable to your present situation * I am 18 years of age or older and I am competent to contract in my own name. I am the parent or legal guardian of the below named pet(s). Please select the paragraph below which is applicable to your present situation * I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I decline the use of my pets images for anything except in hospital medical records and profile images. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.