Owner(S) Must Be 18 Years Or Older *

Preferred Language *

English
Spanish

Pet Insurance *

Yes
No

Owner’s Name *

First

Last

Spouse

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Email Address *

Date of Birth *

Employer *

Work Phone *

Additional Authorized Owners/agents: (Anyone You Give Authorization To Make Decisions Regarding Your Pet's Health. Must Be Over 18 Years Old.)

Name *

First

Last

Phone *

Name *

First

Last

Phone *

How did you hear about us? Client Referral: Name *

Pet’s Name *

Social Media *

By signing below, I understand and agree to the following policies: • ALL FEES ARE TO BE PAID at the time services are rendered. We do not offer any form of billing or extend credit. • There is a $35.00 Cancellation/Rescheduling fee for any procedure not cancelled/rescheduled 72 hours PRIOR to scheduled procedure. • A $25.00 late fee will be assessed each month for any outstanding balance 30 days past due. Accounts past due over 90 days will be subject to collections. • A $25.00 fee will be charged for returned checks. • For some treatments or hospitalized care, a deposit is required. Treatment plans requiring comprehensive care of $200.00 or more, will require a minimum 50% deposit to begin your pet's treatment.

I allow Downey Vet. Hosp. to share my pet’s medical records with other clinics, boarding facilities, etc. as needed. *

Yes
No

I allow Downey Vet. Hosp. to take pictures of either myself, family and pets. *

Yes
No

I allow Downey Vet. Hosp. to use me or my pet’s image or likeliness for marketing purposes (i.e. social media). *

Yes
No

Date *

Pet Information

Pet's Name *

Date of Birth *

Breed *

Color *

Sex *

Male
Female

Neutered *

Yes
No

Micro Chip *

Do you have a second pet? *

Yes
No

Pet's Name *

Date of Birth *

Breed *

Color *

Sex *

Male
Female

Neutered *

Yes
No

Micro Chip *

client Information and Financial Form

Client Information and Financial Form

Pet Information

We proudly serve the pets of Downey and beyond