Client Information Form - Rogue Equine & Companion Animal Clinic

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Todays Date?

Please tell us how you heard about us*

Referral from friend, family or acquaintance
Referral from another veterinarian or clinic
Sign on Highway 62
Google
Facebook
Website
Already an existing customer

Are you an agent or representative of the owner?*

Yes
No

If you indicate yes, please complete the following sections. Otherwise please skip to the owner section.

Agent Information

Agent Name

First Last

Date of Birth - (Agent)*

Agent Mobile Number

Agent's Mobile Carrier

US Cellular
ATT
T Mobile

Agent Email Address

Who do we communicate with?

Agent
Owner

Owner Information - Person Responsible

Owner Name*

First Last

Owner Mailing Address (if different, otherwise leave blank)

Street Address Address Line 2 City State ZIP Code

Owner Physical Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth (Owner-Person Responsible)*

Owner Mobile Phone Number*

Owner's Mobile Carrier*

US Cellular
ATT
T Mobile

Owner Email

Animal Information

Your Animal's Name*

First

Species (choose one)*

Breed (please fill in)*

Sex (please choose one)*

Color*

Please note color.

Animal's Date of Birth

OR list approximate age based on YR/MO (example 1yr/6mo)

Horses only - Please note location (boarding), if not at home address.

Street Address City Facility Name

Photo of your animal - for their medical record only - Optional

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.

Consent to use photo - Optional. This consent is separate from medical record storage.

By checking this box, I agree to allow Rogue Equine & Companion Animal to store and share the submitted photo as noted below.

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.

Optional: additional animals to list; please press the "+" sign at the end of the row for additional rows/animals to add.

Name	Species	Breed	Sex	Age	Color	Location (if not home physical address)

Access to Previous Medical Records: Please note this is required for all small animal appointments. Please provide the clinic name and city where located. A staff member will call.

Clinic Name and Clity

Consent*

I agree to Rogue Equine & Companion Animal's payment for services policy.

Payment is due at the time of services, or upon presentation of an invoice/statement. This means "Due on Receipt". 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, am 18 years of age or older at the time of signing, and I acknowledge responsibility for payment.
Please note - payment policy is "Due on Receipt", which means by next business day. Cash, Debit and Credit Cards are accepted for payment. Zelle or similar forms may be used for payment, however a "Hold" is required to secure payment until these transactions complete.
If I request/require advance notification prior to processing, I agree to receive such notification by EMAIL in the format of an invoice or statement and will respond immediately if a discrepancy is discovered.
If payment is not received under the terms stated above, the invoice due amount plus a $26.00 fee is transferred to a third party billing service for processing. This fee is a pass-through cost charged by the third party billing entity. This is in addition to interest applied (2.0%) to balances due over 30 days.
Whereas the card on file or a replacement card is provided for payment, I agree that processing will take place and a 3.0% card charge fee will be added, within 2 business days, after an invoice or statement has been sent - by email.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.

Signature of owner or agent.*

Email

This field is for validation purposes and should be left unchanged.