Client Information Form

I understand that professional fees are to be paid at the time services are rendered and that deposits are required on all hospitalized and surgical patients. Cash, All major credit cards, and CareCredit are accepted for your convenience. I AGREE AND CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.

AUTHORIZATION TO DISCLOSE

By signing below, I authorize Lake Forest Animal Clinic to disclose my contact information, including but not limited to, my name and address, and information about my pet, including its name, breed, size, color, and other identifying markers to third parties for the purpose of providing vaccine reminders, releasing medical records to requesting veterinarians, providing appointment reminders, issuing product recalls, providing wellness or other veterinary health care information or other special veterinary information that may be of interest to pet owners. This Authorization to Disclose is intended as my written authorization pursuant to California Business and Professions Code section 4857 is limited to the items listed above and does not authorize the disclosure of my pet(s)’ medical records beyond what is specifically authorized pursuant to section 4857.