New Client / New Patient Form

We currently service customers in the state of Kentucky
Leave this blank if you prefer not to be contacted here, even in the case of an emergency
Name, Relation to you, Phone #
Please list one pet per form
We only service canine and feline companions at this time.
Doctor, Hospital and Location
Name, dose, and frequency of drug
Mark all that apply
Mark all that apply
Name, Protein Source, Amount fed per meal, Frequency
Food, Medications, Insects, etc
If yes, which vaccine(s)
Please indicate if it was a 1 year or 3 year vaccine.
I authorize The Advetcate, LLC to use, reproduce, and/or publish photographs and/or video that may pertain to my pet — including my pet’s image, likeness and/or sound without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on The Advetcate’s Internet Web Page or its other social media sites. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, The Advetcate, LLC may publish materials, use my pets’ name, photograph, and/or make reference to my pet(s) in any manner that The Advetcate, LLC deems appropriate in order to promote/publicize/educate service opportunities.
PAYMENT TERMS: Our preferred methods of payment include: Debit and Credit cards (Visa, Mastercard, American Express, Discover). In signing this agreement, I assume full financial responsibility for all charges incurred for the care of my pet(s). I understand that payment for the entire medical plan is required when services are rendered, and if I fail to pay the entire amount at the time services are rendered, that I agree to pay any and all reasonable costs of collection in the event that collection efforts become necessary.
I hereby authorize The Advetcate, LLC and all assistants of its choice to administer any medical and/or surgical procedures as is considered therapeutically and/or diagnostically necessary. I also hereby release The Advetcate, LLC and all its assistants, from any liability by any reason of any act herein above authorized. I understand every effort will be made to achieve a successful outcome and that The Advetcate, LLC and all of its assistants will perform all possible safety procedures while handling my pet(s).
Typing my legal name in the boxes above using any device, means or action, indicates that I agree my electronic signature is the legal equivalent of my manual/handwritten signature on this Agreement. I have read, understood, and accept the Payment Terms and Client Agreement listed above. I am also consenting to the legally binding terms and conditions of this agreement, and agree that I the owner or responsible party of the pet listed on this form.
Typing my legal name in the boxes above using any device, means or action, indicates that I agree my electronic signature is the legal equivalent of my manual/handwritten signature on this Agreement. I have read, understood, and accept the Payment Terms and Client Agreement listed above. I am also consenting to the legally binding terms and conditions of this agreement, and agree that I the owner or responsible party of the pet listed on this form.