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    Kingstowne Cat Clinic, LLC

    I hereby give my permission to the business entity known as the Kingstowne Cat Clinic to:

    1. Maintain my personal information for purposes of maintaining a record of myself and my pets.
    2. Transmit my pet or pet’s medical record to the facility of my choice, should I so request it.

    Furthermore, I understand that payment is due at time of services rendered. I understand that the Kingstowne Cat Clinic is unable to serve as a creditor and cannot extend credit for services rendered.

    Please be advised: Kingstowne Cat Clinic does not have in-house care, 24 hour medical staff outside of normal business hours which are as follows:
    Monday: 8am-6pm
    Tuesday: 8am-6pm
    Wednesday: 8am-6pm
    Thursday: 8am-6pm
    Friday: 8am-6pm

    In the event of an overnight surgery or boarding, a staff member will be here to check on/provide food and any medications twice daily.

    Owner Information

    Owner's Name:

    Spouse/Other:

    Address:

    City:

    State:

    Zip:

    Email:

    Occupation:

    Home Phone:

    Cell Phone:

    How do you prefer we contact you?:

    How did you hear about our practice?:

    If referred, please provide the name:

    First Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Second Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Third Kitty

    Name:

    Breed:

    DOB:

    Sex:

    Color:

    Microchip #:

    Upload Records:

    Please Read Carefully Before Signing

    Kingstowne Cat Clinic has business and medical staffing hours as follows:
    1. Monday and Thursday: 8:00 am to 7:00 pm
    2. Tuesday, Wednesday, and Friday: 8:00 am to 6:00 pm
    3. Weekends and Holidays: Closed
    Therefore, this is to inform you that we have no in-house, on duty continuous medical staff care on:
    a) Weekdays from Closing time until the following business day at 8:00 am.
    b) Weekends from Closing time on Fridays or Saturday (depending on the alternating weekend) until 8:00 am on the following Monday.
    c) Holidays from Closing time before the Holiday until the opening time the day after the Holiday

    *Signature: (Please type your name)