Back to Pet Kare Clinic Patient Forms Client Information "*" indicates required fields Are you a New or Existing Client?* New Client Existing Client Name and EmailName* First Last Email* Is this a new email address? This is a new email address Existing Clients: What Information Would You Like to Update?* Phone information Address information Spouse or other contact information Permissions and release agreements Financial responsibility Phone InformationMobile Phone*Second PhonePreferred Phones (Check all that Apply) Mobile Voice Mobile Text Second Phone Work PhoneIf needed can we call you at work? Yes No Address InformationMailing Address* Mailing Address Mailing 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 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 Spouse or Other Contact InfoSpouse/Other First Last Spouse/Other Mobile PhonePermissionsPhoto Release Pet Kare Clinic may post photos of my pets on their website and social media platforms Release of Medical Records I authorize release of my pets' medical records to other clinics Please Print Your Name to Authorize Release of Photos and/or Records* Noted: My name constitutes a legally binding agreement.Payment of FeesPROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMEDWho will be responsible for authorizating procedures and paying for services?* First Last Signature* Date* MM slash DD slash YYYY How did you hear about Pet Kare Clinic?How did you hear about us? Online Search Friend Newspaper Other Other: If a friend referred you, whom may we thank? NameThis field is for validation purposes and should be left unchanged.