CLIENT INFORMATION

Date *

Name *

First

Last

D.O.B *

Preferred Pronouns

Spouse's Name

First

Last

Driver's License Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Secondary Phone Number

Email Address *

Contact Preference

Text
Voicemail
Email

How were you referred to our hospital? *

PET INFORMATION

Pet's Name *

Breed *

Birth/Hatch Date/Approximate Age *

Sex *

Male
Female

Color *

How long have you had your pet? *

Heartworm Test/Prevention *

Yes
No

Do you have second pet?

Yes
No

Pet's Name *

Breed *

Birth/Hatch Date/Approximate Age *

Sex *

Male
Female

Color *

How long have you had your pet? *

Heartworm Test/Prevention *

Yes
No

Do you have third pet?

Yes
No

Pet's Name *

Breed *

Birth/Hatch Date/Approximate Age *

Sex *

Male
Female

Color *

How long have you had your pet? *

Heartworm Test/Prevention *

Yes
No

Any previous records? *

Any allergies to vaccinations or medications? *

Is your pet on any special diets or medications? *

I have been advised that for safety reasons, my pet, upon arriving or leaving AEAC, must be either restrained appropriately or in a carrier. *Failure to follow this policy, may result in my pet’s harm by other patients in the reception area. *

I have read and agree AEAC's policy

By signing this form, I am stating that I am over the age of 18yrs. *

Yes, I am over the age of 18
No, I am not over the age of 18

Avian and Exotic Animal Care respects your privacy and we are committed to protect the personal information that you share with us. Personal information is defined as information that can be used to identify you, or your pet, and to contact you. Your personal information will never be given out, sold, or shared with third parties, with the exception of outside laboratories/consultants for the purpose of diagnostics for your pet. We are committed to making you feel comfortable as our client and we understand how important your pet’s health is and that your pet’s health is a personal and private subject. If you have any questions or concerns regarding the privacy of your personal information please do not hesitate to ask any member of our team. *

I have read and agree to the following

Our goal at Avian and Exotic Animal Care is to give excellent service in a timely manner. Due to the nature of emergencies, which may need urgent and immediate care, we may ask for your patience. We will keep you informed regarding wait times and offer you other options. *

I have read and agree to the following

AVIAN AND EXOTIC ANIMAL CARE EXPECTS PAYMENT IN FULL AT THE TIME SERVICES ARE RENDERED. We accept cash, credit cards, and Care Credit. For extensive diagnostics, hospitalization, and surgery, we will provide you with a Treatment Plan. If your pet is left with us for any reason, please be prepared to pay in advance for your pet’s care per the Treatment Plan. Should you choose, we can take credit card payment over the phone, with proper documentation. LATE PAYMENTS OF OVER 30 DAYS ARE SUBJECT TO FINANCE CHARGES PER MONTH, AND OUTSTANDING CHARGES MAY BE SENT TO COLLECTIONS. *

I have read and agree to the following

Client Signature *

Clear Signature

Appointment Cancellation/ No Show/ Late Policy

We also understand that unplanned issues can come up and you may need to cancel or move your appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 24hrs in advance. Our veterinarians want to be available to all of our patients. When clients do not show up, another patient loses the opportunity to be seen. Although we have always had a cancellation policy, circumstances have caused us to enforce a policy of charging for Late arrivals, No Shows, and appointments not cancelled with 24hr notice.

As of November 2024, there are now charges for the following:

Late appointments
No-Shows or failure to cancel with 24 hour notice
Late, No-Shows, and Cancellations within 48 hours for SURGERIES or PRIMATE APPOINTMENTS, due to extra preparation for these specific visits.

All Late, No Show, or failure to cancel fees must be paid before further services are completed.

Thank you for being a valued client and for entrusting your pet to our care. Thank you also for your understanding and cooperation as we institute this policy. Our hope is to open otherwise unused appointment slots for those urgent pets that need to be seen and to better serve all of our clients and patients’ needs.

Please Initial *

Mutual Respect & Client Relationship

We believe the best client relationships are built on open communication, kindness, and mutual respect. We are always happy to hear your questions, concerns, and feedback, and we ask that you extend the same respect to our team. We reserve the right to discontinue services if the client relationship becomes disrespectful, abusive, threatening, or otherwise prevents us from providing the level of service we strive for.

Please initial and date below to acknowledge the need for mutual respect in our veterinary patient-client relationship and that you understand that services can be discontinued if this is not maintained:

Please Initial *

Date *

PHOTO & CONTENT RELEASE FORM

At Avian and Exotic Animal Care, we enjoy sharing our patients’ photos and stories within our hospital & online. We would love your permission to share your pet’s image & story. Sharing stories is simply a fun way to assist us in educating other pet owners about pet health.

Help us by reviewing the statement below:

I hereby grant Avian and Exotic Animal Care the right to photograph my pet and copyright, use & publish said images. Publication includes both print and electronic publication, including – but not limited to – our website, our blog & our social media.

I grant Avian and Exotic Animal Care the right to copyright, use and publish my pet’s story for any lawful purpose, including – but not limited to – social media content, blog content and education content. *

I AGREE and give Avian and Exotic Animal Care the right to share my pet’s photo/story.
I DISAGREE. Please do not share my pet’s photo/story.

Pet(s) Name *

Client Name *

Client Signature *

Clear Signature

Client Information Form