Rogue Equine & Companion Animal Clinic

for compassionate, personalized, expert veterinary medical care
serving Southern Oregon and Northern California.

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Client Information Form

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Client Information Form

This completed form is required by law in order for us to provide service. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent.

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    MM slash DD slash YYYY
    If you indicate yes, please complete the following sections. Otherwise please skip to the owner section.
  • Agent Information

  • Owner Information

  • Animal Information

  • Please note color.
  • MM slash DD slash YYYY
  • Max. file size: 1 MB.
    Spacing and time allowing, we will store a photo of your animal for the purpose of identification in the event of separation or loss, or confirmation of identification.
  • Use of photo is explicitly for sharing with others our amazing patients and four legged friends. Photo to be shared anonymously - animal and owner. Not intended for commercial use other than web site, FB or Instagram.
  • NameSpeciesBreedSexAgeColorLocation (if not home physical address) 
  • Clinic Name and Clity
  • Payment is due at the time of services, or upon presentation of an invoice/statement. In some cases, an estimate may be presented for payment in advance. In all cases, I, the owner or agent, and that person signing this form is responsible for payment. In addition, I understand and agree that in the event of default I may be subject to additional collection and/or attorney's fees when applicable. All disputes to be resolved in Jackson County, Oregon.
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  • This field is for validation purposes and should be left unchanged.
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