Form
Your Name
First Name
Last Name
Your spouse's name (so they may be on the record and make medical decisions)
First Name
Last Name
Name
First Name
Last Name
Email (this should be the best email to send reminders for vaccines, exams, and other information)
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number (this should be the best number to reach you via text; some reminders come via text such as appointment reminders)
Please enter a valid phone number.
Home/Alternate Number
Please enter a valid phone number.
Your pet's name
Name
Nickname
Species
Dog
Cat
Other
Breed
Color
Date of birth (day/month/year)
Gender
Female spayed
Female intact
Male neutered
Male intact
Does your pet have any known allergies or previous vaccine reactions? If yes, please list below:
Who was your pet's previous veterinary clinic(s)?
No previous veterinary clinics (new puppy, kitten, etc)
Local Animal Shelter
Previous vet (please list below)
Previous Vet Clinic's Name, Phone #
When was the last time your pet was seen by a veterinarian?
Reason for visit (check all that apply)
Annual Physical Exam
Exam for problem
Establish care/switching clinics
Do you have insurance for your pet? Please list company and policy number if yes
We ask that all fees be paid at the time of service. We accept cash, personal checks (with identification), Visa, Mastercard, Discover, American Express, and CareCredit. We do not offer in-house payment plans. Past due accounts are subject to late fees, and those turned over the collections are subject to collection and/or legal fees.
I agree
Do we have permission to post photos of your pet online (in our clinic Facebook page, or on our clinic website?)
Yes
No
Did someone refer you to our clinic? If yes, please put their name in the box below:
Why are you seeking to switch clinics? (i.e. a move, clinic closed, etc)
Is there anyone else who we should contact to make medical decisions for your pet who is not listed above?
Please type your initials as confirmation you have read and agree with the above statements:
Please enter today's date (day/month/year)
Please verify that you are human
*
Submit
Should be Empty: