Client Information Form

Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear client profile, we need you to fill out the new Client Information form below. Your data is safe with us. Only fully completed forms are accepted.

Email Notification Opt-In:

YesNo

Text Message Notification (via Cell Phone) Opt-In:

YesNo

Post Card Reminder sent to you when your pets are due for annual exam:

YesNo

Should Ness Exotic to send completed records to the referring hospital?

YesNo

I hereby give Ness Exotic Wellness Center permission to take photographs of me and/or my pet for the purpose of posting on Facebook, Clinic Website, and/or other social media outlets. I choose to release and discharge Ness Exotic Wellness Center from any and all claims arising out of the use of the photos. I am above the age of 18.

AcceptDecline

To the best of my knowledge, the information provided above and on the patient history form is accurate and complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged.