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Client & Patient Info

Owner Information:

Primary Owner

First Name(Required)

Last Name

Email Address(Required)

Phone Number(Required)

Street Address

Apt/Unit

City

State

Zip

Secondary Owner

First Name

Last Name

Phone Number

Pet Information

Name(Required)

Species(Required)

Breed

Sex(Required)

Spayed/Neutered?(Required)

Yes

Color

Medications

Previous Veterinarian Information

Phone(Required)

Email(Required)

Second pet

Name

Species

Breed

Sex

Spayed/Neutered?

Yes

Color

Medications

Previous Veterinarian Information

Phone

Additional Information

How did you first learn about us?(Required)

Google

Yelp

Referral

Other

Whom may we thank?

Authorization for Professional Services

I hereby authorize Cactus Creek Animal Hospital (CCAH) to perform such diagnostics, therapeutic, and surgical procedures as are necessary and advisable for treatment and maintenance of my pet’s health and well-being.

The nature of such services has been described to me to my satisfaction, and while I expect all procedures to be done to the best abilities of the professional staff, I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I agree to pay all charges incurred at the time of discharge of my pet, including reasonable attorney’s fees and cost of collection in the event of default. I also authorize the hospital director and his/her staff to provide veterinary services as requested or in emergency circumstances to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis until further advised in writing.

Texting and Applications

Cactus Creek Animal Hospital contacts clients through texting, e-mail and text as well as share your name, pet’s name, email address, address and phone number with our associates and partners to facilitate this process.

Photography/Video/ Audio Release

I, the undersigned, hereby consent to the use by Cactus Creek Animal Hospital, and those acting with permission and authority of CCAH, of all photographs, videotape, or other images or recordings that CCAH has taken of me and/or my pet, or in which I and/or my pet may be included, for all purposes, in any and all media including the internet, without limitation, including promotion, solicitation, advertising or trade.

I am fully aware that my likeness may appear in materials available to staff of CCAH, and individuals outside of the CCAH community, for marketing, educational and training purposes.

I understand that all images in which I participate, including film, photogenic prints, digital files or video are the exclusive property of CCAH and I grant to CCAH the unrestricted right to copyright, publish and republish the images.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Get in touch

(702) 675-3800

509 Marks Street
Henderson, NV 89014

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509 Marks Street
Henderson, NV 89014

Home
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Contact Us

Make An Appointment

(702) 675-3800

Business Hours

MONDAY- FRIDAY: 8:00 AM- 6:00 PM
SATURDAY: 9:00 AM – 5:00 PM
SUNDAY: CLOSED

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