Client InformationPrimary Contact(Required) First Last Primary Phone(Required)Do you want to receive text messages?(Required) YES NO Email(Required) Secondary Contact First Last Secondary Contact PhoneDo you want to receive text messages? YES NO Secondary Contact Email Is there anyone else you would like to have on your account who can make medical decisions on you and your pet’s behalf?Pet Sitter, Family Member, etc.Are there any other contact methods you would like on your account?Home Phone, Work Email, etc. Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about us?(Required)Drive byOnlineReferralWho Referred You to Us?What is most important to you regarding your veterinary care and experience?Pet InformationPlease list all the pets you have in your household:(Required)NameSpecies/BreedGenderAge Add RemovePolicies and AcknowledgmentsI acknowledge that I have engaged Martinez Animal Hospital for the care and treatment of my pet(s). I understand that while the clinic will provide the best possible care, there are no guarantees or warranties regarding the outcome of any medical procedures or treatments. I agree to assume full financial responsibility for all services rendered.(Required) I AGREE I grant Martinez Animal Hospital permission to take photographs or videos of my pet for promotional, educational, or informational purposes. I understand that these images may be used in print or digital media, including but not limited to the clinic's website and social media channels. I waive any rights to compensation or ownership of these images.(Required) YES NO, do not take pictures of my pet I agree to pay all charges for services provided by Martinez Animal Hospital upon discharge of my pet. Payments can be made by most major credit cards, Care Credit or cash.(Required) I AGREE A credit card processing fee of up to 3% will be applied to all transactions made using credit/debit cards. This fee will be itemized separately on your billing statement, and you will have the option to choose alternative payment methods if you wish to avoid this fee. Any price you are quoted is the “Cash Price” and does not include the processing fee.(Required) I UNDERSTAND I understand and accept the clinic's cancellation policy, which requires a minimum of 24 hours' notice for cancellations; otherwise, a cancellation fee may apply.(Required) I UNDERSTAND I acknowledge the clinic's late policy, which states that while efforts will be made to accommodate appointments, if I am more than 10 minutes late, Martinez Animal Hospital may not be able to provide services, and a $10 late fee may apply.(Required) I UNDERSTAND I also understand that Martinez Animal Hospital may require a deposit for certain services, and I am willing to comply with such requests.(Required) I UNDERSTAND
