"*" indicates required fields Step 1 of 3 33% Primary Owner Name* First Last ***Note: Primary Owner will be displayed as the Name/Number we will contact for anything pertaining to the pets on this account.How did you hear about us?*Drive-byFacebookFriendGoogleI am a prior clientNextdoorOtherReferred by Whom?Enter First and Last NameName of Previous Veterinary Clinic***Please contact your prior clinic and request records be emailed to info@copperpointvet.com PRIOR to first appointmentPrimary Owner Email Address*Co-Owner Name First Last Co-Owner EmailAddress* 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 Owner Mobile Number*Owner Home NumberOwner Work NumberCo-Owner Mobile NumberPlease set your communication preferences by making selections below:Email Yes No Primary Owner Mobile – Call Me Yes No Work Number Yes No Home Number Yes No Co-Owner Mobile - Call Yes No PHOTO PERMISSION: I hereby grant permission to use any photographs taken of myself or my pet, in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become your property and will not be returned. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. In signing this consent, I give authorization to use my name and my pet’s name and information as provided in this New Client Form.* Yes - I consent! No - No photos! MY PET INFORMATIONPlease ENTER ALL items for each Pet requested below. Add rows as needed by clicking the "+" at the end of each pet's row to accommodate the number of Pets to be added to your account. Note this form will not be accepted if each item is not provided for each pet. Enter NA if your pet does not have a microchip:*Pet's NameSpecify DOG or CATBreed(s)Microchip# (Enter N/A if not microchipped):Date of Birth/Estimated AgeColor(s)Sex (Male or Female)Is pet Spayed or Neutered? Add Remove I hereby authorize the Copper Point veterinarians to examine, prescribe for, or treat my pets(s). I assume full responsibility for all charges incurred in the care of this/these animal(s). I understand these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures. I have read and understand the Copper Point "Cancellation/No-Show Policy - We respectfully request 24 hours advanced notice to cancel an appointment. When you do not contact us to cancel an appointment, you may be preventing another patient from receiving much needed treatment. Repeated failures to cancel appointments within the requested timeframe will result in a $60 non-refundable deposit to schedule appointments in the future."New Client Name must be entered below to acknowledge the Copper Point Policies Above:*CommentsThis field is for validation purposes and should be left unchanged.