New Client Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone*Home PhoneWork PhoneEmail* Place of EmploymentDrivers License#*Emergency contact name and phone number:Whom may we thank for referring you?How did you hear about us?First Animal’s Name:*Date of Birth/Age*Species*CanineFelineBreed:*Gender:*MaleFemaleSpayed./Neutered?*YesNoColor:*Approximate date and type of last exam and vaccines:*Previous health conditions/concerns:*Reason for visit today:*Second Animal’s Name:Date of Birth/AgeSpeciesCanineFelineBreed:Gender:MaleFemaleSpayed./Neutered?YesNoColor:Approximate date and type of last exam and vaccines:Previous health conditions/concerns:Reason for visit today:Communication Consent FormWe at Jefferson Animal Clinic consider you and your pet(s) as part of our family. During the year, we would like your permission to communicate with you regarding things that can be of assistance to you and your beloved pet(s). We regularly send out e-newsletters with helpful tips for the health care of your pet(s) and would love to have you follow us on Facebook! We also want to be able to send a “thank you” for any referral you might give, a best wish for a Birthday or holiday, special offers on health care products that we recommend and of course, reminders for upcoming appointments. By receiving your permission, we know that we are communicating with you because you want to receive information that will benefit the health and well-being of your pet(s). Please check (X) below to tell us which way you are willing to be communicated with:Preferred method of contact*Direct Mail other than “Reminders” (post office)Phone other than “Reminders”TextEmailPhoneEmail We respect your privacy and will not sell, rent or trade any of your personally identifiable information. The above are for communications from our hospital to you, and will not be used for any other reason.Date* Date Format: MM slash DD slash YYYY Type Out Full Name* First Last Thank you for being a part of our family! We truly care about you and your pet(s) and look forward to communicating with you throughout the year!Release of Information for Media or Website PublicationJefferson Animal Clinic has a Facebook page and a website. We like to take pictures of our newly adopted pets and share them. We also like to educate people and share interesting facts and findings. If you would like to authorize Jefferson Animal Clinic to share these photos and information (no personal information whatsoever) please print your name and your pet’s name and mark which websites we are authorized to share to. If you would like NO media or information to be shared at all please print your name and your pet’s name and mark the DECLINED section at the bottom of this page.Client’s Name* First Last Patient(s) Name* First Last After an explanation of its intended use, I authorize the staff at Jefferson Animal Clinic to release portions of my pet(s) medical history and record, including personal recollections, radiographs, photographs, video images or other images to use with the following media entity(ies):* Select All The Journal of the AVMA The Journal of the AAHA The Journal of Veterinary Internal Medicine Veterinary Surgery The Compendium on CE for the Practicing Veterinarian Veterinary Forums Facebook Instagram Jefferson Animal Clinic website VIN OtherPlease specify I understand that no client names will be used unless specific authorization has been obtained. I also understand that this information may be used in the print media, social media, on a brochure or on the Jefferson Animal Clinic website for public education purposes and agree to its use in that manner.I, the undersigned, am interested in educating the public about my pet(s) condition and medical care and authorize Jefferson Animal Clinic’s employees to use such materials for this purpose. I agree not to file any claim for revenue or lawsuit for damages against Jefferson Animal Clinic with respect to the release of this information.Signature (or printed name) of Owner or Authorized Agent*Date* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.