Client Update Form

Primary Pet Owner Name:

First Last

Are you the primary pet owner?

Yes
No

If you are not the owner what is your relationship to the primary pet owner?

How may we address you?

First Name
Dr.
Miss
Ms.
Mrs.
Mr.

Pronouns

She/Her/Hers
He/Him/His
They/Them/Theirs

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Primary Phone

Secondary Phone

Secondary Owner Name:

First Last

Relationship to Owner

Secondary Owner Email

Secondary Owner Phone Number

Please list all pet(s) in your household:

Pet insurance provider? (If applicable)

Please list all pet(s) with health insurance?

List any other veterinary provider who have treated your pets in the last 12 months.

Do you give Seville Veterinary Hospital permission to contact the veterinary practice above for your pet (s) records?

Yes
No
I will bring the records with me for you to copy.

Do you give SVH consent to release your pet (s) medical records and vaccination records to the following:

Hold CTRL key to select multiple

Please list any party that you do not want SVH to release records to:

How would you prefer to receive bloodwork and or any other test results for your pet(s)?

Phone
Text
Email

The following individuals have your permission to make medical decisions pertaining to my pet(s)health. The individual listed are also authorized to receive my pet(s) medical record.

Please list name, relationship to you, and phone number.

Photography Notice*

Yes, I will allow Seville Veterinary Hospital to use my pet’s image and name on their social media.
No, I will not allow Seville Veterinary Hospital to use my pet’s image beyond their private medical history.

Seville Veterinary Hospital sometimes shares patient’s cute photos on social media.

Authorization and Acknowledgement:*

I agree to the below policy.

Seville Veterinary Hospital does not provide 24-hour care. Seville Veterinary Hospital provides owner(s) with Best Medicine options to make informed decisions regarding their pet(s) health. I hereby authorize Seville Veterinary to examine, prescribe and treat my pet(s). I understand depending on the medication prescribed I have the option to use a pharmacy other than SVH for my pet(s) medications. I understand Seville Veterinary Hospital uses video and audio monitoring/surveillance for the safety of clients, patients, employees, and staff training.

Payment Policy*

I agree to the below policy.

I understand payment is due at the time of service. If your pet is need of specialty surgery, procedure, or treatment a deposit will be required.
Payment options available; Cash, Visa, Mastercard, American Express, Discover, and Care Credit.
I verify I have read and understand all notices listed above. I also verify that the information I have entered is true and correct, and this box acts as my signature of acknowledgement.

Date

I have filled out the above form to the best of my knowledge and agree to all required terms.*

Please type your name above to act as a digital signature.

Monday	7:30 am – 6:00 pm
Tuesday	7:30 am – 7:00 pm
Wednesday	7:30 am – 6:00 pm
Thursday	7:30 am – 7:00 pm
Friday	7:30 am – 6:00 pm
Saturday	8:00 am – 2:00 pm
Sunday	Closed

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Hours of Operation