Client Information Form

UPDATE FOR 2026

We are currently scheduling new client appointments on a very limited basis. Please be sure to fill out both this form with your information and one Patient History Questionnaire per cat you'd like to schedule. Once those are received, you will be added to our wait list and we will reach out when there is an available appointment.

Owner Information

First & Middle Initial

Last

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

By providing my phone number, I consent to receive SMS text messages from Cats Exclusive for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg data rates may apply. Reply HELP for support. Reply STOP to opt out. Refer to our privacy policy and terms and conditions for more information.

I Consent to receive SMS text messages
I Do Not Consent to receive SMS text messages

Email Address

Preferred

Employer

Position

Spouse or Partner

First & Middle Initial

Last

Employer

Position

Work Phone

Emergency Contact

Name

Relationship

Phone

Cat(s)

Please include a list of your cat's names:

How Did You Find Us?

Other

Whom may we thank for referring you to us?

Optional: If applies, reason for changing veterinarian

Financial Policy:
I hereby authorize the veterinarian to examine, treat, and prescribe for the above-described animal(s). I assume all responsibility for all charges incurred in the care of this animal. I understand that payment is due at time services are rendered and that there may be a deposit required for any hospitalized treatment. Acceptable forms of payment are cash, checks (up to the amount of $300.00), debit and credit cards (Mastercard/Visa/Discover) and Care Credit.

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The Cats Exclusive St. Francis Fund was created in 2002 by our kindhearted doctors and staff to provide urgent, life-saving medical care for cats in need.

Learn how you can help!