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.

    Today's date

    Email Notification Opt-In:

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

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

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

    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.

    Accept

    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.

    Your Signature: