Recent Posts Updated Consent For Treatment Form ... Updated Consent For Treatment Form "*" indicates required fields Date MM slash DD slash YYYY Client InformationName* First Last Phone*Primary number will receive text appointment reminders and be the first point of contact.Email* Spouse/Secondary Owner Name First Last An authorized individual with legal ownership to the pet listed below.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 Patient InformationHow many pets are you registering?12345Name of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Color*Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedSecond PetName of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Color*Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedThird PetName of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Color*Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedFourth PetName of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Color*Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedFifth PetName of Cat*Birthdate of Cat*Sex* Male Female Is Your Cat Spayed or Neutered?* Yes No Is your cat declawed?* Yes No Color*Is your cat?* Domesticated Short Hair Domestic Medium Hair Domestic Long Hair Pure Breed Cat BreedConsentI 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 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 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*
