Client Update Form Client Update FormHOW DID YOU LEARN ABOUT US?*DATE* Date Format: MM slash DD slash YYYY MAIN CONTACT NAME*YOUR DATE OF BIRTH:* Date Format: MM slash DD slash YYYY 1st NUMBER TO CALL*Please Circle:CellHomeWork2nd NUMBER TO CALL*Please Circle:CellHomeWorkADDRESS* Street Address City State / Province / Region ZIP / Postal Code EMAIL ADDRESS* PLACE OF EMPLOYMENTSPOUSE/OR OTHER OWNERDATE OF BIRTH: Date Format: MM slash DD slash YYYY 1st NUMBER TO CALLPlease Circle:CellHomeWork2nd NUMBER TO CALLPlease Circle:CellHomeWorkEMAIL ADDRESS PLACE OF EMPLOYMENTWOULD YOU LIKE TO RECEIVE TEXTS FOR THINGS SUCH AS APPOINTMENT REMINDERS, PREVENTATIVE REMINDERS, AND FECAL RESULTS?*YesNoIf yes, please list which phone number you would like text messages sent toOTHER PETS?EMERGENCY CONTACTNAME(OTHER THAN YOUR SPOUSE OR YOURSELF)PHONEWE ARE IN THE PROCESS OF COMPUTERIZING OUR FILES. ARE YOU INTERESTED INRECEIVING EMAIL REMINDERS IN LIEU OF REGULAR MAIL?*YesNoI AUTHORIZE AKIN HILLS TO USE MY AND MY PET’S PICTURE IN THE INTERNET, INCLUDING ON FACEBOOK.*YesNoTHIS DOCUMENT WILL REMAIN IN EFFECT FOR 3 YEARS BUT MUST BE SIGNED YEARLY. A PHOTOCOPY OF THIS AGREEMENT IS TO BE CONSIDERED VALID AS AN ORIGINAL. I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT IN FULL AT TIME OF SERVICE, AND AM RESPONSIBLE FOR ALL FEES, INCLUDING THOSE INCURED AS A RESULT OF THE COLLECTION PROCESS, IF NECESSARY.*I AgreeSignature*
