New Client Form

Please call to schedule an appointment before filling out this form.

We are glad to have the opportunity to care for you and your pet(s). To ensure your pet gets the best care we can offer, please fill out this form completely.

Owner's Name *

Secondary Contact *

Secondary Contact's relationship to owner *

Address Line 1 *

Address Line 2 *

Phone *

Email *

Is this the same address at which the pet currently resides?

Pet's Primary Address *

Pet's Primary Address - line 2 *

Pet(s) Name: *

Species *

Breed *

Gender *

Age *

Color *

Is your pet microchipped? *

Please provide microchip number *

Do you have a copy of your pet's current rabies certificates with vaccination expiration date? *

Which Ohana Pet Hospital location would you like your appointment to be? *

Authorization (please read): I hereby authorize Ohana Pet Hospital to render medical care for my pet(s) as deemed necessary by the veterinarian. I assume responsibility for all charges incurred in the care of the pet(s). I also understand that all fees are due at the time of service. It is our policy to provide a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization will be provided. A deposit may be required depending upon the amount of the estimate. All fees are due upon release of patient. *

Model Agreement (please read): I, the undersigned, do hereby consent and agree that Ohana Pet Hospital, its employees, or agents have the right to take photographs, video, or digital recordings of me* and/or my pet(s) to use in any and all media, now or hereafter known, and exclusively for the purpose of marketing, promotion and outreach. I further consent that my name* and/or pet(s) name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to Ohana Pet Hospital, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my or pet’s identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me or my pet(s), either for initial or subsequent transmission or playback. I also understand that Ohana Pet Hospital is not responsible for any expense or liability incurred as a result of my or my pet’s participation in this recording, including medical expenses due to any sickness or injury incurred as a result. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. If you would like to opt-out of the use of your likeness in photographs, video, or digital recordings as well as the use of your name in any and all Ohana Pet Hospital media, but don't mind your pet(s) name and likeness being used, please select the option of "Pet only." *

Electronic Signature Acknowledgement (please read): This Acknowledgement and Certification of Understanding is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you for all documents within this task.

805.658.7387

805.933.1341

New Client Form

Please call to schedule an appointment before filling out this form.

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