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. HiddenTodays Date? MM slash DD slash YYYY 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 InformationAgent Name First Last Date of Birth - (Agent)* MM slash DD slash YYYY Agent Mobile NumberAgent's Mobile Carrier US Cellular ATT T Mobile Agent Email Address Who do we communicate with? Agent Owner Owner Information - Person ResponsibleOwner Name* First Last Owner Mailing Address (if different, otherwise leave blank) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth (Owner-Person Responsible)* MM slash DD slash YYYY Owner Mobile Phone Number*Owner's Mobile Carrier* US Cellular ATT T Mobile Owner Email Animal InformationYour Animal's Name* First Species (choose one)*EquineCanineFelineOtherBreed (please fill in)* Sex (please choose one)*Female (Intact)Female SpayedMale (Intact)Male Neutered/Gelded (Gelding)Color* Please note color.Animal's Date of Birth* MM slash DD slash YYYY Horses only - Please note location (boarding), if not at home address. Street Address City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Facility Name Photo of your animal - for their medical record only - OptionalMax. 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.NameSpeciesBreedSexAgeColorLocation (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 ClityConsent* 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. 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. 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.*Untitled EmailThis field is for validation purposes and should be left unchanged. Δ