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

    Last Name

    First Name

    Spouse or Significant Other

    Cellphone

    Address

    City

    Country

    State

    Zip Code

    Home Phone

    Cell Phone

    Work Phone

    Email

    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:

    Driver’s License #

    State

    Place & Address of Employment

    How did you find out about us?

    If referred, by whom

    Other Animal Hospital & Veterinarian

    Why did you choose us?

    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.

    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: