{"id":3987,"date":"2021-06-21T15:25:02","date_gmt":"2021-06-21T15:25:02","guid":{"rendered":"http:\/\/localhost\/victor\/wordpress\/?page_id=3987"},"modified":"2024-03-29T02:11:45","modified_gmt":"2024-03-29T02:11:45","slug":"new-client-form","status":"publish","type":"page","link":"https:\/\/laveterinarycenter.com\/jeffersonpark\/new-client-form\/","title":{"rendered":"New Client Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3987\" class=\"elementor elementor-3987\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3f80024e elementor-section-height-min-height elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"3f80024e\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7665e4c5\" data-id=\"7665e4c5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-64e8015a elementor-widget elementor-widget-heading\" data-id=\"64e8015a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">New Client Register<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-623ff75a elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"623ff75a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4602e799\" data-id=\"4602e799\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-19e49962 elementor-widget elementor-widget-spacer\" data-id=\"19e49962\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-14bfb8bc elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"14bfb8bc\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-791bdded\" data-id=\"791bdded\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9cf4352 elementor-widget elementor-widget-shortcode\" data-id=\"9cf4352\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4005-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"4005\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/jeffersonpark\/wp-json\/wp\/v2\/pages\/3987#wpcf7-f4005-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"4005\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.2.4.1\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4005-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div id=\"responsive-form\" class=\"modern-cf7-form\">\n\n <!-- PRIMARY OWNER -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Primary Owner\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"first-name\">First Name <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"first-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"last-name\">Last Name <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"last-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"datep-545\">Date of Birth <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"datep-545\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"datep-545\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"datep-545\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- SECONDARY OWNER -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Secondary Owner <span class=\"optional\">(Optional)<\/span>\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"sfirst-name\">First Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sfirst-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"sfirst-name\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"sfirst-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"slast-name\">Last Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"slast-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"slast-name\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"slast-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"sdatep-545\">Date of Birth<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sdatep-545\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" id=\"sdatep-545\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"sdatep-545\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- ADDRESS -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Address Information\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"address\">Street Address <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"address\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter Your Address\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"your-city\">City <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"your-city\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"your-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"States\">State <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"States\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" id=\"States\" aria-required=\"true\" aria-invalid=\"false\" name=\"States\"><option value=\"Alabama\">Alabama<\/option><option value=\"Alaska\">Alaska<\/option><option value=\"Arizona\">Arizona<\/option><option value=\"Arkansas\">Arkansas<\/option><option value=\"California\">California<\/option><option value=\"Colorado\">Colorado<\/option><option value=\"Connecticut\">Connecticut<\/option><option value=\"Delaware\">Delaware<\/option><option value=\"Florida\">Florida<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Idaho\">Idaho<\/option><option value=\"Illinois\">Illinois<\/option><option value=\"Indiana\">Indiana<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"Kansas\">Kansas<\/option><option value=\"Kentucky\">Kentucky<\/option><option value=\"Louisiana\">Louisiana<\/option><option value=\"Maine\">Maine<\/option><option value=\"Maryland\">Maryland<\/option><option value=\"Massachusetts\">Massachusetts<\/option><option value=\"Michigan\">Michigan<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Mississippi\">Mississippi<\/option><option value=\"Missouri\">Missouri<\/option><option value=\"Montana\">Montana<\/option><option value=\"Nebraska\">Nebraska<\/option><option value=\"Nevada\">Nevada<\/option><option value=\"New Hampshire\">New Hampshire<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"New Mexico\">New Mexico<\/option><option value=\"New York\">New York<\/option><option value=\"North Carolina\">North Carolina<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"Ohio\">Ohio<\/option><option value=\"Oklahoma\">Oklahoma<\/option><option value=\"Oregon\">Oregon<\/option><option value=\"Pennsylvania\">Pennsylvania<\/option><option value=\"Rhode Island\">Rhode Island<\/option><option value=\"South Carolina\">South Carolina<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Tennessee\">Tennessee<\/option><option value=\"Texas\">Texas<\/option><option value=\"Utah\">Utah<\/option><option value=\"Vermont\">Vermont<\/option><option value=\"Virginia\">Virginia<\/option><option value=\"Washington\">Washington<\/option><option value=\"West Virginia\">West Virginia<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Wyoming\">Wyoming<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"your-zip\">Zip Code <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"your-zip\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Zip Code\" value=\"\" type=\"text\" name=\"your-zip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- CONTACT & COMMUNICATION -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Contact Information\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"p-phone\">Preferred Contact Phone # <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"p-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"p-phone\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"(555) 000-0000\" value=\"\" type=\"tel\" name=\"p-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Phone Type<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ptype\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"ptype\" value=\"Home\" \/><span class=\"wpcf7-list-item-label\">Home<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"ptype\" value=\"Work\" \/><span class=\"wpcf7-list-item-label\">Work<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"ptype\" value=\"Cell\" \/><span class=\"wpcf7-list-item-label\">Cell<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"c-phone\">Alternate Contact Phone #<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"c-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" id=\"c-phone\" aria-invalid=\"false\" placeholder=\"(555) 000-0000\" value=\"\" type=\"tel\" name=\"c-phone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Phone Type<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ctype\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"ctype\" value=\"Home\" \/><span class=\"wpcf7-list-item-label\">Home<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"ctype\" value=\"Work\" \/><span class=\"wpcf7-list-item-label\">Work<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"ctype\" value=\"Cell\" \/><span class=\"wpcf7-list-item-label\">Cell<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"email-780\">Email Address <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-780\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" id=\"email-780\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"name@example.com\" value=\"\" type=\"email\" name=\"email-780\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">May we send you text message notifications?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"notify-txt\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"notify-txt\" value=\"Yes, please\" \/><span class=\"wpcf7-list-item-label\">Yes, please<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"notify-txt\" value=\"No, thank you\" \/><span class=\"wpcf7-list-item-label\">No, thank you<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Preferred Method of Communication<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"com-method\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"com-method\" value=\"Call\" \/><span class=\"wpcf7-list-item-label\">Call<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"com-method\" value=\"Text\" \/><span class=\"wpcf7-list-item-label\">Text<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"com-method\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"com-method\" value=\"Postmail\" \/><span class=\"wpcf7-list-item-label\">Postmail<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- REFERRAL -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Referral Information\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">How did you learn about us?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"reference\" value=\"Walk\/drive by\" \/><span class=\"wpcf7-list-item-label\">Walk\/drive by<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"reference\" value=\"Here Previously\" \/><span class=\"wpcf7-list-item-label\">Here Previously<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"reference\" value=\"Internet\" \/><span class=\"wpcf7-list-item-label\">Internet<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"reference\" value=\"Yelp\" \/><span class=\"wpcf7-list-item-label\">Yelp<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"reference\" value=\"Google\" \/><span class=\"wpcf7-list-item-label\">Google<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"reference\" value=\"Friend Relative\" \/><span class=\"wpcf7-list-item-label\">Friend Relative<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"refer-name\">If friend\/relative: Whom may we thank?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"refer-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"refer-name\" aria-invalid=\"false\" placeholder=\"Name of friend or relative\" value=\"\" type=\"text\" name=\"refer-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- APPOINTMENT INFO -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Appointment Details\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p class=\"form-note\">If you don't have an appointment, please call us at <a style=\"color:black;\" href=\"tel:3236857131\">323-685-7131<\/a> to schedule today!\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"app-date\">Appointment Date <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"app-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"app-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"app-date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"app-time\">Appointment Time <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"app-time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"app-time\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g., 10:00 AM\" value=\"\" type=\"text\" name=\"app-time\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- PET INFORMATION -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Patient (Pet) Information\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"petname\">Pet Name <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"petname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"petname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pet&#039;s name\" value=\"\" type=\"text\" name=\"petname\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Dog or Cat <span class=\"required\">*<\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dorg\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dorg\" value=\"Dog\" \/><span class=\"wpcf7-list-item-label\">Dog<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dorg\" value=\"Cat\" \/><span class=\"wpcf7-list-item-label\">Cat<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"breed\">Breed <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"breed\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"breed\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Breed\" value=\"\" type=\"text\" name=\"breed\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"age\">Age \/ Date of Birth <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"age\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age or DOB\" value=\"\" type=\"text\" name=\"age\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"color\">Color <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"color\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Color \/ Markings\" value=\"\" type=\"text\" name=\"color\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Sex<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"sex\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"sex\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">Spayed \/ Neutered<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"spayed\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"spayed\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"spayed\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"mchip\">Microchip # <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mchip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"mchip\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Microchip number\" value=\"\" type=\"text\" name=\"mchip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-half\">\n\t\t\t\t<p><label for=\"pdocter\">Previous Doctor \/ Clinic Name <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pdocter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"pdocter\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Clinic Name\" value=\"\" type=\"text\" name=\"pdocter\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">May we request records?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"records\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"records\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"records\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"vhistory\">Vaccination History <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vhistory\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"vhistory\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Brief history\" value=\"\" type=\"text\" name=\"vhistory\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full file-upload-box\">\n\t\t\t\t<p><label for=\"upload-file-854\">Upload Attachments (Ex: X-ray Images, Previous Test Reports)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"upload-file-854\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" id=\"upload-file-854\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"upload-file-854\" data-type=\"jpeg|png|jpg|pdf|\" data-limit=\"3000000\" data-min=\"1\" data-max=\"5\" data-id=\"4005\" data-version=\"free version 1.4.1\" accept=\".jpeg, .png, .jpg, .pdf, .\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full file-upload-box\">\n\t\t\t\t<p><label for=\"upload-file-a\">Additional Attachments<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"upload-file-a\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" id=\"upload-file-a\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"upload-file-a\" data-type=\"jpeg|png|jpg|pdf|\" data-limit=\"3000000\" data-min=\"1\" data-max=\"5\" data-id=\"4005\" data-version=\"free version 1.4.1\" accept=\".jpeg, .png, .jpg, .pdf, .\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full radio-group\">\n\t\t\t\t<p><span class=\"label-heading\">May we use photos of your pets on social media?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"photos\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"photos\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"photos\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n<hr class=\"form-divider\" \/>\n\n <!-- TERMS & SIGNATURES -->\n\t<fieldset class=\"form-section\">\n\t\t<legend class=\"section-title\">Authorization & Signatures\n\t\t<\/legend>\n\t\t<div class=\"form-grid\">\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<div class=\"terms-box\">\n\t\t\t\t\t<p>I, the undersigned, owner, or authorized agent of the above patient hereby authorize the admitting doctor (and his designated associates\/assistants) to administer such treatment as needed for the benefit of this patient. I also consent to the administration of such anesthetics as needed. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred to this patient and agree to pay all such charges at the time the patient is released. <strong>PAYMENT IS DUE AT THE TIME OF SERVICE.<\/strong>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"checkbox-wrapper\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"agree-499\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\" id=\"agree-499\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"agree-499[]\" value=\"I have read and understand\" \/><span class=\"wpcf7-list-item-label\">I have read and understand<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full signature-block\">\n\t\t\t\t<p><label for=\"signature-p\">Signature of Primary Owner <span class=\"required\">*<\/span><\/label><br \/>\n<div class=\"wpcf7-form-control-signature-global-wrap wpcf7-form-control-wrap\" data-field-id=\"signature-p\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:300px;height:200px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas class=\"signature-p\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_signature-p_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap signature-p\">\n\t\t\t\t  <input aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"hidden\" name=\"signature-p\" id=\"wpcf7_input_signature-p\" class=\"wpcf7-form-control wpcf7-signature\" \/><input type=\"hidden\" name=\"signature-p-attachment\" id=\"wpcf7_input_signature-p_attachment\" class=\"wpcf7-form-control wpcf7-signature\" \/><input type=\"hidden\" name=\"signature-p-inline\" id=\"wpcf7_input_signature-p_inline\" class=\"wpcf7-form-control wpcf7-signature\" \/>\n\t\t\t\t\n\t\t\t<\/span>\n\t\t\t\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"date-psignature\">Today's Date <span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-psignature\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"date-psignature\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-psignature\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full signature-block\">\n\t\t\t\t<p><label for=\"signature-s\">Signature of Secondary Owner<\/label><br \/>\n<div class=\"wpcf7-form-control-signature-global-wrap wpcf7-form-control-wrap\" data-field-id=\"signature-s\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:300px;height:200px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas class=\"signature-s\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_signature-s_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap signature-s\">\n\t\t\t\t  <input aria-invalid=\"false\" value=\"\" type=\"hidden\" name=\"signature-s\" id=\"wpcf7_input_signature-s\" class=\"wpcf7-form-control wpcf7-signature\" \/><input type=\"hidden\" name=\"signature-s-attachment\" id=\"wpcf7_input_signature-s_attachment\" class=\"wpcf7-form-control wpcf7-signature\" \/><input type=\"hidden\" name=\"signature-s-inline\" id=\"wpcf7_input_signature-s_inline\" class=\"wpcf7-form-control wpcf7-signature\" \/>\n\t\t\t\t\n\t\t\t<\/span>\n\t\t\t\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"column-full\">\n\t\t\t\t<p><label for=\"date-ssignature\">Today's Date<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-ssignature\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" id=\"date-ssignature\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-ssignature\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/fieldset>\n\n <!-- SUBMIT BUTTON -->\n\t<div class=\"form-row submit-row\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Form\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><input type=\"text\" class=\"wpcf7_hp_field\" name=\"wpcf7_hp_field\" value=\"\" tabindex=\"-1\" autocomplete=\"off\" \/><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-4fcb7e48 elementor-widget elementor-widget-spacer\" data-id=\"4fcb7e48\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-66f3827f elementor-widget elementor-widget-spacer\" data-id=\"66f3827f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>New Client Register<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-3987","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>New Client Registration Form - Los Angeles Veterinary Center<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/laveterinarycenter.com\/jeffersonpark\/new-client-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"New Client Registration Form - Los Angeles Veterinary Center\" \/>\n<meta property=\"og:description\" content=\"New Client Register\" \/>\n<meta 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