"*" indicates required fields Are you a Current Client or New Client?* New Client Current Client Have we seen this patient before?* Yes No Date MM slash DD slash YYYY Name* First Last Phone*Primary number will receive text appointment reminders and be the first point of contact.Email* Appointment type* Wellness Surgery Sick/Injured (If urgent, please call us at 610-398-3556) Second Opinion Additional Comments:*Preferred Date #1 MM slash DD slash YYYY Preferred TimeMorningMid-Day (11-2pm)Late AfternoonPreferred Date #2 MM slash DD slash YYYY Preferred TimeMorningMid-Day (11-2pm)Late AfternoonPreferred Date #3 MM slash DD slash YYYY Preferred TimeMorningMid-Day (11-2pm)Late AfternoonSpouse/Secondary Owner Full Name First Last Spouse/Secondary Owner PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referred ByName of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedColor*Where has your cat received previous veterinary care? (Veterinarian, shelter, rescue, etc.) Please provide name of facility. Write none if no previous medical history.*I am responsible for having records emailed to catstaff@verizon.net or faxed to 610-398-4486 upon booking.* Agree I hereby authorize the veterinarian to examine, prescribe for, or treat my cat. I assume responsibility for all charges incurred in the care of my cat.* Agree I understand that a booking fee of $50.00 per patient ($150 for surgeries) will be collected upon scheduling. Due to limited availability, this fee would be due by end of business day or the appointment will be cancelled. Additional charges will be paid at the time of release unless prior arrangements have been made. This fee will be applied to your appointment. This fee is non-refundable should you change or cancel with less than 24 hours notice.* Agree I authorize Allentown Cat Clinic, PC to use photos and/or videos of my cat(s) for any promotional materials regarding Allentown Cat Clinic, PC programs, facilities or services. Such likenesses will not be sold to other parties. Promotional materials bearing these likenesses may be distributed for free to the public and posted on the Allentown Cat Clinic website and/or social media platforms. The Allentown Cat Clinic, PC reserves the right to use any photo or likenesses for a time period beginning when this form is signed and ending upon written request of the owner of this cat.* I agree I decline Notice of Audio and Video Recording: For the safety, training, and quality assurance of our patients, clients, and team members, Allentown Cat Clinic, PC utilizes audio and video recording in various areas of the hospital. These recordings may include both visual and sound-based capture of interactions, including but not limited to client communication, telephone calls and patient care activities. By signing below, you acknowledge that you have been informed of the use of audio and video recording within the facility and grant permission for Allentown Cat Clinic, PC to record and store such footage for lawful and appropriate use, including quality assurance, training, and internal review purposes. We take privacy and confidentiality seriously and ensure that all recordings are handled in accordance with applicable laws and hospital policy.* I acknowledge and agree Electronic Signature of Owner*
