Client Authorization Form

Please fill out this form prior to your first scheduled visit to our practice.

Name*
First Name Last Name
Phone*
Email*
Secondary Name
Please enter if you have anyone else in your household who is an owner of your pets (spouse, significant other, family member)
First Name Last Name
Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I declare that I am/we are 18 years of age or older and am/are the legal owners(s) of the patients listed in my file and have sole authorization to make decisions regarding my pet(s):*
- Yes
- No
How did you hear about our practice?*
- Drive by
- Internet Search
- Website
- Social Media
- Yellow Pages
- Advertisement
- Friend or Family Referral
If Friend or Family, is there anyone we can thank for the referral?
We, North Penn Animal Hospital, use our social media pages (i.e.: Facebook, Instagram and YouTube), website and TV slideshow to share pet photos, videos and interesting stories. However, we cannot do it alone! Will you help us by granting permission to use photos/videos of your pet(s), their story and details of his or her medical history to help educate other clients? We will never share your name or your pet’s last name. If at any time you wish to have your pet’s photos, videos or stories removed, please alert our staff*
- Yes
- No
I authorize the release of my pet's medical and vaccine records to grooming, boarding, rescue adoption and veterinary facilities without signed release.*
- Yes
- No
I hereby authorize the veterinarian to examine, prescribe for, treat, or perform surgery or emergency care on my pet(s). I assume responsibility for all charges incurred in the care for this animal. I also understand that these charges will be paid in advance or at time of release.*
- Yes
- No
In order to keep costs down, we are unable to bill or carry accounts. Payment for all services and products must be paid in full at time of visit or discharge. If for any reason your pet is admitted into the hospital, we will require a deposit, which equals 1/2 of your pet’s estimate costs for his/her hospitalization. For your convenience we accept Cash, Check, Visa, MasterCard, Discover, American Express and offer CareCredit to qualifying clients.*
- I agree
- I disagree
Signature*
Please enter your name and date below
Client Name Date
You may e-mail your pet(s) records to clientcare@npah.com

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 8:00pm
Thursday	8:00am – 8:00pm
Friday	8:00am – 8:00pm
Saturday	9:00am – 2:00pm
Sunday	Closed

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Client Authorization Form

Client Authorization Form

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Client Name	Date

Client Authorization Form

Client Authorization Form

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