{"id":469,"date":"2025-02-07T18:06:09","date_gmt":"2025-02-07T18:06:09","guid":{"rendered":"https:\/\/classenviewvet.com\/?page_id=469"},"modified":"2025-02-07T19:14:41","modified_gmt":"2025-02-07T19:14:41","slug":"new-client-information-form","status":"publish","type":"page","link":"https:\/\/classenviewvet.com\/index.php\/new-client-information-form\/","title":{"rendered":"New Client Information Form"},"content":{"rendered":"\n<p><\/p>\n\n\n<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-d87a494f-fa48-44f0-90da-ebc97fbcb05d wpforms-render-modern\" id=\"wpforms-475\"><form id=\"wpforms-form-475\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"475\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/469\" data-token=\"1ac9102263d3c45256af5045c62f3236\" data-token-time=\"1776760686\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-475-field_4-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Primary Pet Owner Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-475-field_4\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][4][first]\" aria-errormessage=\"wpforms-475-field_4-error\" required><label for=\"wpforms-475-field_4\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-475-field_4-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][4][last]\" aria-errormessage=\"wpforms-475-field_4-last-error\" required><label for=\"wpforms-475-field_4-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-475-field_5-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Secondary Pet Owner Name<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-475-field_5\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][5][first]\" aria-errormessage=\"wpforms-475-field_5-error\" ><label for=\"wpforms-475-field_5\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-475-field_5-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][5][last]\" aria-errormessage=\"wpforms-475-field_5-last-error\" ><label for=\"wpforms-475-field_5-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-475-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_6\">Home Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-475-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-475-field_6-error\" aria-describedby=\"wpforms-475-field_6-description\" required><div id=\"wpforms-475-field_6-description\" class=\"wpforms-field-description\">Street Address<\/div><\/div><div id=\"wpforms-475-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_7\">City<\/label><input type=\"text\" id=\"wpforms-475-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-475-field_7-error\" ><\/div><div id=\"wpforms-475-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_8\">State<\/label><input type=\"text\" id=\"wpforms-475-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-475-field_8-error\" ><\/div>\t\t<div id=\"wpforms-475-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-475-field_1\" >Your Phone Pet?<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-475-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-475-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_9\">Zip Code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-475-field_9\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99999\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-475-field_9-error\" required><\/div><div id=\"wpforms-475-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_10\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-475-field_10\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"+1 (999)-(9999)\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-475-field_10-error\" required><\/div><div id=\"wpforms-475-field_11-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_11\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-475-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" spellcheck=\"false\" aria-errormessage=\"wpforms-475-field_11-error\" required><\/div><div id=\"wpforms-475-field_12-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Preferred Method Of Contact Regarding Your Pet?<\/legend><ul id=\"wpforms-475-field_12\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-475-field_12_1\" name=\"wpforms[fields][12]\" value=\"Phone Call\" aria-errormessage=\"wpforms-475-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_12_1\">Phone Call<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-475-field_12_2\" name=\"wpforms[fields][12]\" value=\"Text\" aria-errormessage=\"wpforms-475-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_12_2\">Text<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-475-field_12_3\" name=\"wpforms[fields][12]\" value=\"Email\" aria-errormessage=\"wpforms-475-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_12_3\">Email<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-475-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">Clients Consent <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-475-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-475-field_15_1\" name=\"wpforms[fields][15][]\" value=\"I understand that all invoices and bills must be paid in full when services are rendered.  For your convenience we accept Visa, Mastercard, Discover, American Express, Care Credit and Cash.  Checks are not accepted as a form of payment at Classen View Veterinary Clinic.  All credit cards must be physically present at time of payment.  We cannot key in or manually enter any credit card information.\" aria-errormessage=\"wpforms-475-field_15_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_15_1\">I understand that all invoices and bills must be paid in full when services are rendered.  For your convenience we accept Visa, Mastercard, Discover, American Express, Care Credit and Cash.  Checks are not accepted as a form of payment at Classen View Veterinary Clinic.  All credit cards must be physically present at time of payment.  We cannot key in or manually enter any credit card information.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-475-field_15_2\" name=\"wpforms[fields][15][]\" value=\"I allow any photos taken by team members at Classen View Veterinary Clinic to be used on Classen View&#039;s social media platforms.  No personal information other than the pets name will be used.\" aria-errormessage=\"wpforms-475-field_15_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_15_2\">I allow any photos taken by team members at Classen View Veterinary Clinic to be used on Classen View&#8217;s social media platforms.  No personal information other than the pets name will be used.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-475-field_15_3\" name=\"wpforms[fields][15][]\" value=\"I do not allow any photos taken by team members at Classen View Veterinary Clinic to be used on Classen View&#039;s social media platforms.  No personal information other than the pets name will be used\" aria-errormessage=\"wpforms-475-field_15_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-475-field_15_3\">I do not allow any photos taken by team members at Classen View Veterinary Clinic to be used on Classen View&#8217;s social media platforms.  No personal information other than the pets name will be used<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-475-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-475-field_16\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-475-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-475-field_16-error\" aria-describedby=\"wpforms-475-field_16-description\" required><div id=\"wpforms-475-field_16-description\" class=\"wpforms-field-description\">By selecting the \u201cSubmit&#8221; button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual\/handwritten signature on this document. By selecting \u201cSubmit\u201d using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor\u2019s parent or legal guardian.\nI may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email. <\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-475-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-475-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-475-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"475\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/469\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-475\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/classenviewvet.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-469","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/469","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/comments?post=469"}],"version-history":[{"count":4,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/469\/revisions"}],"predecessor-version":[{"id":482,"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/pages\/469\/revisions\/482"}],"wp:attachment":[{"href":"https:\/\/classenviewvet.com\/index.php\/wp-json\/wp\/v2\/media?parent=469"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}