New Client Form New Client Form Date * Pet Owner's Name * Pet Owner's Name First First Last Last Spouse/Other Name Spouse/Other Name First First Last Last Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Cell Phone Home Phone * Work Phone ER Contact * Employer's Name * Employer's Phone * How Did You Hear About Us? * Website Google Clinic Sign Yelp Magazine Word of Mouth OtherOther Pet's Name * Species * Dog Cat Please Indicate If Your Pet Is... * Male - Neutered Male - Not Neutered Female - Spayed Female - Not Spayed Breed * Color * Date of Birth * Is Your Pet Up to Date on Vaccines? * Yes No Date of Vaccines * Previous Vet/Hospital Name & Phone Number * Is Your Pet on Any Medications? * Yes No Do You Have Pet Insurance? * Yes No Please List Any Known Drug Allergies * Please List Any Surgeries * PAYMENT POLICY: All fees are due at the time services are rendered. We Accept cash, checks, all major credit cards and offer Care Credit for surgical and extensive medical services. A deposit of 50% of initial estimate is required when an animal is admitted for medical/surgical services. The remainder of your payment is due upon discharge of your pet. My signature indicates that I understand that I am responsible for all fees incurred in treating my pet. I hereby authorize the veterinarian to examine, prescribe for or treat my pet, and to have my pet's photo displayed on the clinic's website and/or Facebook. I agree to pay for the reasonable costs of collection, attorney fees & court costs in the even that collection efforts become necessary. Signature * signature keyboard Clear Captcha Submit If you are human, leave this field blank.
