FM 1488 Animal Medical Center - New Client Form

Name

First NameLast Name
Add A Spouse or Partner?
Spouse/Partner/None

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Spouse/partner email
example@example.com
Primary phone
Enter phone numberFormat: (000) 000-0000.
What type of phone?
Spouse/partner's phone
Enter phone numberFormat: (000) 000-0000.
What type of phone?
Secondary phone
Enter phone numberFormat: (000) 000-0000.
Work phone
Enter phone numberFormat: (000) 000-0000.
Spouse/partner's work phone
Enter phone numberFormat: (000) 000-0000.
How were you referred to our practice?

Other
If you were referred by a family member or friend, please let us know who to thank:
Is it okay to release your pet's medical records to other veterinarians, referral facilities and/or boarding/ grooming facilities?
Social Media Consent: I hereby give FM 1488 Animal Medical Center to take photograph(s) of my pet’s for the purposes of posting them to FM 1488 Animal Medical Center’s website and/or other social media sites (including but not limited to Facebook, YouTube, Instagram, Twitter, etc...). I understand that in some cases information regarding my pet’s medical condition, including diagnosis and treatments, may be posted to these same social media sites. Please check the level of release you authorize.
Financial Policy: FULL PAYMENT IS DUE AT TIME OF SERVICE. NO CHECKS ACCEPTED.

We accept cash, Debit, Visa, Mastercard, American Express, Discover, and Apple payments. We offer convenient payment options through Care Credit and Scratch Pay as well.

If you have pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance company. In no way are we responsible for your agreement with the insurance provider.

For first-time clients dropping off their pets for veterinary care, a deposit of $300 will be required.

Any treatment plan that requires comprehensive care of more than $500, may require a deposit to begin your pet(s) treatment.

Any client who does not show for an appointment they have scheduled with us may be subject to pre-paying for office examinations in order to schedule future appointments with our facility.

All clients are responsible for full payment at the time of services. You are responsible for payment even if the final bill is not completed at the time of your visit.
By signing below, I am verifying that I am of legal age to authorize consent to the above in the state of Texas on this date
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