Client Information Sheet To view the fillable PDF of this form, click here. Client Information Sheet Today's Date * Title * Mr. Mrs. Ms. Dr. Name * 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 Parish Home Phone * Cell Phone Email * Employer Work Phone Spouse/Significant Other Phone Emergency Contact(If other than Spouse/Significant Other) Phone Authorized Representatives for Communication (if other than person(s) listed above) The client authorizes the following individual(s) to communicate with Avian & Exotic Animal Hospital of Louisiana until revoked in writing: Name Select below to authorize Medical Decisions Health Updates Financial Decisions Name Select below to authorize Medical Decisions Health Updates Financial Decisions How did you learn about our practice? * Facebook Our Website Yelp YP.com Search Engine Pet Store Veterinarian OtherOther Which Veterinarian? * I understand a $26.25 cancellation fee will be accessed on all appointments cancelled within a 24 hour period. * I understand Photo/Name Release: I agree to allow Avian & Exotic Animal Hospital of Louisiana to use my name, my pets name and photographs of myself and/or my pet for any lawful purpose including publicity, illustration, advertising, web-site, FaceBook, Twitter, Instagram, You Tube and other media. I agree ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept: Mastercard / Visa / American Express / Discover / Check / Cash / Care Credit Signature of person responsible for payment * signature keyboard Clear Date * If other than client please print name and relationship to client Captcha Submit If you are human, leave this field blank.
