New Client Form ONLY

1

Primary Client Name* This field is required.

First Name

Last Name

2

Primary Client Phone Number* This field is required.Best number to call or text for your appointment.

Area Code

Phone Number

3

Is this primary number a cell phone?* This field is required.

YESNO

4

Primary Client Email* This field is required.

example@example.com

5

Preferred method of contact* This field is required.

Call

Text

Email

6

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

Please list anyone else authorized to make decisions on your account.

Name

Relationship to Client

Phone Number

8

Pet InsurancePlease include company and policy number

9

Do you want us to provide information about Trupanion Pet Insurance?* This field is required.

YESNO

10

Patient Information* This field is required.

Name

Sex

Breed/Species

Color

Age or Date of Birth

Spayed or Neutered (Yes or No)

11

Patient #2 Information

Name

Sex

Breed/Species

Color

Age or Date of Birth

Spayed or Neutered (Yes or No)

12

Patient #3 Information

Name

Sex

Breed/Species

Color

Age or Date of Birth

Spayed or Neutered (Yes or No)

13

How did you hear about us?* This field is required.

Please select:

14

If you were referred by a current client, who can we thank?

15

Please provide ANY previous veterinarian or vaccination records before your appointment (including breeder or adoption records)* This field is required.We MUST have a copy of any records prior to your appointment. If you have a copy of the records please email them to allcreatures@nva.com or take a picture and text them to us BEFORE your appointment, you can text images to 602-493-5090. If you are unable to send us a copy of the records, please include name, city, state and contact info of your previous veterinarian below. If your pet does not have any medical, adoption, or vaccine records type "No Records". If you have a physical copy of records and are NOT ABLE to digitally send them via text or email please let us know.

16

I acknowledge that if records are not received prior to the appointment, your appointment is subject to cancellation.* This field is required.

Yes

17

I grant to All Creatures Animal Clinic, its representatives and employees the right to copyright, use and publish photos of my pet in print and/or electronically. I agree that All Creatures Animal Clinic may use such photographs of my pet with or without my pet’s name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.* This field is required.

YESNO

18

I understand that all payment is due the day services are rendered. A deposit may be required prior to any procedures. Any balance that becomes 30 days past due may incur a finance charge of 10% per annum.* This field is required.

Yes

19

I understand an $85 no-show/late rescheduling fee will be charged if your appointment is canceled without 24-hour notice. If you do cancel your appointment without notice, a non-refundable deposit of $85 will be required before scheduling any future appointments.* This field is required.

Yes

20

I understand that all pets must be on a leash or contained in a carrier.* This field is required.

Yes

21

I acknowledge and agree to the following Code of ConductAll Creatures Animal Clinic seeks to continually provide a welcoming and safe environment which ensures trust and respect for all people and pets. We have a zero-tolerance policy for the following behavior:• Verbal abuse, malicious or harmful statements about others, profanity or disrespect directed at a person or pet• Any form of harassment• Discriminatory comments and/or actions• Intimidation tactics and/or threats• Allowing your pet to intimidate or threaten a person or another pet• Public disclosure of another’s private information• Suspicion of being under the influence of alcohol or behavior-altering drugs• Failure to comply with requests from our staff, including leashing/restraining your pet In the event that your behavior is problematic, we reserve the right to discontinue services immediately. This policy is strictly enforced and non-compliance will result in corrective measures being taken, which may include termination of veterinary care at All Creatures Animal Clinic, being asked to leave the property, and the potential of involvement by law enforcement.

YESNO

22

Signature* This field is required.

Clear

23

I understand a $66 no-show/late rescheduling fee will be charged if your appointment is canceled without 24-hour notice. If you do cancel your appointment without notice, a non-refundable deposit of $66 will be required before scheduling any future appointments.

Todo

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