New Client Form Step 1 of 333%Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneRecommended by Whom?Place of EmploymentEmergency Contact*Will be used if you cannot be reached. First PetSelect One:*DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP I grant permission to have my pet(s) vaccine records sent to another hospital/boarding / grooming/daycare facility.Initials* I grant to Mariposa Veterinary Wellness Center, its representatives and employees the right to take photographs of me & my property in connection with my visit. I authorize Mariposa Veterinary Wellness Center, its assigns & transferees to copyright, use & publish the same in print and/or electronically. I agree Mariposa Veterinary Wellness Center may use such photographs of me with or without my name & for any lawful purpose, including for example such purposes as publicity, illustration, advertising & web content. I have read and understand the above.SignatureDate Date Format: MM slash DD slash YYYY CONSENT TO COMPLEMENTARY AND/OR ALTERNATIVE VETERINARY MEDICAL CARE(“Non-Western / “Non-Traditional” Veterinary Treatment)THE UNDERSIGNED hereby certifies that I am the owner of the above named animal and I am over the eighteen years of age.The undersigned recognizes and acknowledges that I am seeking a form of treatment for my animal that varies from traditional evidence-based “Western” veterinary medicine a/k/a “Traditional” veterinary medicine; hereafter complementary and/or alternative veterinary medicine (“CAVM”).The undersigned understands the diagnostic and/or treatment procedures for CAVM are likely to vary considerably from those offered at “Western” or “Traditional” veterinary clinics, colleges, facilities, hospitals or practices. The types of CAVM treatment includes: (a) acupuncture; (b) acutherapy; (c) acupressure; (d) homeopathic; (e) chiropractic; (f) electrical therapy; (g) food therapy; (h) herbal / plant therapy; (i) holistic medicine; (j) integrative therapies; (k) laser therapy; (l) magnetic therapy; (m) manual / manipulative therapies; (n) massage therapy; (o) nutraceutical therapy; (p) osteopathic; (q) phytotherapy; and/or others.The undersigned appreciates and understands that not all animal patients can or will benefit from one or more of these CAVM approaches. The undersigned fully accepts that the attending veterinarian(s) may consider, discuss, recommend and/or suggest other modes of care for my animal including referrals to other veterinarians who practice “Western” or “Traditional” veterinary medicine, board-certified veterinarians in particular veterinary disciplines, or veterinarians who practice a combination of “Western” / “Traditional” veterinary medicine and CAVM.The undersigned also understands and accepts that the attending veterinarian(s) may decide not to offer or provide discussed or suggested CAVM care for my animal without further clinical or diagnostic evaluation or testing or may decide not to offer such CAVM care because there is no apparent veterinary medical reason that it would benefit my animal.The undersigned acknowledges and is aware that the practice of veterinary medicine is not an exact science and, thus, no assurances or guarantees for successful treatment can nor have been made. Further, the Mariposa Veterinary Wellness Center, L.L.C. veterinarian(s) have encouraged me to ask all questions I might have and the veterinarian (s) agreed not to proceed with this CAVM care until each of my questions had been answered to my full satisfaction. Also, with the opportunity to consult with other veterinarians before commencing CAVM care on my animal.Last, the undersigned consents to the provision of requisite clinical and/or diagnostic procedures and CAVM treatment provided at Mariposa Veterinary Wellness Center, L.L.C.Signature*Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.