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Hours 2444 Honolulu Ave
Montrose, CA 91020

Client Intake Form

Owner's Full Name*

Owner's DOB*

Owner's DL#

Secondary Owner:

Current Mailing Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Contact

Name

Phone Number

Email

If a current client referred you, please let us know so we can thanks them!

CLIENT NOTICE

All professional fees are to be paid AT THE TIME SERVICES ARE RENDERED.
A written estimate may be provided at your request.

ALL MISSED DOCTOR APPOINTMENTS WILL INCUR A $45 FEE. ALL MISSED TECHNICIAN APPOINTMENTS WILL INCUR A $ 25 FEE. WE ALSO ARE IMPLEMENTING A LATE POLICY WHERE WE CAN'T GUARANTEE SEEING THE PET PAST 5 MINUTES OF THE SCHEDULED APPOINTMENT TIME.

Initial Here*

Please check to authorize the release of medical records to any person not on record. (i.e: groomer, other hospitals, etc.)*

Agree

If you are not the pets owner please fill out the portion below: I AM AWARE THAT I AM FINANCIALLY RESPONSIBLE FOR TODAY'S VISIT. MPH IS NOT RESPONSIBLE FOR ARRANGING 3rd PARTY PAYMENTS.

Full Name

Relationship to owner:

Address

Phone

Please opt-in to SMS messaging from our hospital.*

Opt-in

I do not wish to receive texts

Montrose Pet Hospital Forms

Montrose Pet Hospital