New Client Information You will only need to fill out the form you see below once to become a new client of ours. CLIENT INFORMATION If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Address 1 * Address 2 City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Home Phone Best Phone Number to Reach You Email * How did you hear about us / who referred you? * Are you interested in alternative medicine for your pet(s)? Yes, I am interested in alternative medicine for my pet(s) No, I am not interested in alternative medicine for my pet(s) PATIENT INFORMATION Please list all of your pets Number of Pets You Own? * Names of pets: Breed(s) of your pet(s): Description (color / markings) of each pet: Age of each pet: Sex of each pet (M/F) use same order: List names of pet(s) neutered or spayed: Weight of each pet in pounds (lbs): Date of last vaccinations (if known) for each pet: In this manner: Name of Pet, Rabies 5/12/2014, Distemper 4/17/2015, Other vaccinations 12/13 2014. Put each pet's vaccination record as above on a separate line. Have any of your pets ever lived outside Florida? If yes, where? DISCLAIMERS & SIGNATURE: BY MY SIGNATURE: I assume responsibility for all charges incurred for services rendered to the patient. Payment or donations are appreciated at the time services are rendered. I understand there is a $35 service charge for returned checks. I understand that any deposits paid for services will go towards the service on the day scheduled, and are nonrefundable or transferrable. I give my permission for the staff of Natural Veterinary Services, Inc to obtain any medical records that may pertain to my pet(s). These records may be collected from any hospital or clinic that my pet(s) has visited in the past or may visit during my time as a client here, and is not limited to any specific ailment or treatment. I have read and understand the disclaimer on the PREVIOUS page. Your Digital signature / Date of signing: Disclaimer statement: I understand that the FDA has not evaluated the efficacy of Bicom Bioresonance, homeopathic remedies, and natural cures. Many holistic products and services offered are not intended to diagnose, treat, prevent, or cure any disease.