Client Authorization Form

Please fill out this form prior to your first scheduled visit to our practice.

Name*
First Name Last Name
Phone*
Email*
Secondary Name
Please enter if you have anyone else in your household who is an owner of your pets/authorized (spouse, significant other, family member)
First Name Last Name
Phone
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
I declare that I am/we are 18 years of age or older and am/are the legal owners(s) of the patients listed in my file and have sole authorization to make decisions regarding my pet(s):*
- Yes
- No
We, North Penn Animal Hospital, use our social media pages (i.e.: Facebook, Instagram and YouTube), website and TV slideshow to share pet photos, videos and interesting stories. However, we cannot do it alone! Will you help us by granting permission to use photos/videos of your pet(s), their story and details of his or her medical history to help educate other clients? We will never share your name or your pet’s last name. If at any time you wish to have your pet’s photos, videos or stories removed, please alert our staff*
- Yes
- No
I authorize the release of my pet's medical and vaccine records to grooming, boarding, rescue adoption and veterinary facilities without signed release.*
- Yes
- No
I hereby authorize the veterinarian to examine, prescribe for, treat, or perform surgery or emergency care on my pet(s). I assume responsibility for all charges incurred in the care for this animal. I also understand that these charges will be paid in advance or at time of release.*
- Yes
- No
In order to keep costs down, we are unable to bill or carry accounts. Payment for all services and products must be paid in full at time of visit or discharge. If for any reason your pet is admitted into the hospital, we will require a deposit, which equals 1/2 of your pet’s estimate costs for his/her hospitalization. For your convenience we accept Cash, Check, Visa, MasterCard, Discover, American Express and offer CareCredit to qualifying clients.*
- I agree
- I disagree
Authorization*
Please enter your name and date to authorize.
Client Signature Date
You may e-mail your pet(s) records to clientcare@npah.com

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Contact

Hospital: 215-855-5853
Boarding: 215-855-3739
Fax: 215-855-9337

1200 Welsh Road
Lansdale, Pennsylvania, 19446

Hospital

Monday-Friday: 8 am–8 pm
Saturday: 9 am – 2 pm
Sunday: Closed

We are closed on the 1st and 3rd Wednesday of the month from 2-3:30 pm for our staff meeting.

Boarding

Monday – Friday:
9 am-12 pm and 4 pm-6 pm
Saturday & Sunday:
9 am -12 pm

Please note: The boarding office is closed on holidays for drop-off and pickup.

Client Signature	Date