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Hours 1516 Glenwood Ave
Raleigh, NC 27608

Client Information Form

Secondary Contact (Name & Phone)

Are you a new, returning, or current client?*

New Client

Returning Client

Current Client (updating my information on file)

Client's Date of Birth (required for controlled drug prescriptions):*

We use e-mail for health service reminders and appointments, but for other communication how would you like for us to contact you?*

Text

Email

Phone Call

Please list any individuals other than the primary contacts who are authorized to pick up or drop off your pet(s) from our hospital (spouse, other family members, friends, pet sitters, etc.).

Please list any individuals other than the primary contacts who are authorized to make medical decisions for your pet.

Do we have your permission to post photos of your pet(s) on our website and/or social media?

Yes

No

How did you learn about us? If you were referred, we'd love to know by whom.

Hayes Barton Animal Hospital