Client Information

Owner Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Secondary #

Email *

Co-Owner Name

First

Last

Relationship

Co-Owner Phone

Pet Information

Enter Pet Details

Pet's Name

Species

Sex

Breed

Photo Consent:

I consent to Peninsula Pet Clinic that they may use photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including such purposes as publicity, illustration, advertising and web content. *

Yes, I accept
No, I decline.

Cancelation Policy:

New clients, and clients who have previously missed appointments, are required to pay a deposit for appointments ($92 for cats/dogs, $112 for exotic pets). All surgical and specialist procedures require a deposit of $150. This deposit will be applied to your balance.

Peninsula Pet Clinic requires 24 hours notice to cancel veterinary and technician appointments, and 48 hours to cancel surgical and specialist procedures.

Cancelation within 24 hours or arrival more than 10 minutes late to your appointment will result in the forfeiture of your deposit.

Cancelation Policy: *

I have read and agree to this policy

Signature *

Clear Signature

Medication Refill Policy

To ensure the best care for your pets, Peninsula Pet Clinic does not process orders for medications or preventatives directly from online suppliers or outside pharmacies (excluding compounding pharmacies for specific formulations). Instead, we are happy to fill your medications in clinic or through our online store for your convenience. *

I have read and agree to this policy.

Signature *

Clear Signature

Authorization for Treatment

I certify that I am the owner/authorized agent for the pet(s) listed on this form. I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet(s). I assume full responsibility for all charges incurred for the care of this animal. I understand that these charges will be paid at the time of service. *

I agree

Signature *

Clear Signature

Date *

Text and Email Consent Form

Client Information

Pet Information

Enter Pet Details

Photo Consent:

Cancelation Policy:

Medication Refill Policy

Authorization for Treatment

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