Online New Client Form

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name*

First NameLast Name
MI
SPOUSE
SS# OR DL#/STATE*
CELL PHONE #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS
example@example.com
YOUR EMPLOYER
SPOUSE EMPLOYER
WORK PHONE
SPOUSE WORK PHONE
ADDITIONAL PHONE
SPOUSE CELL PHONE
HOW DID YOU LEARN ABOUT OUR CLINIC?
PET HEALTH HISTORY
NAME OF PET*
TYPE OF PET*

DOGCAT
SEX*

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
BREED*
COLOR*
BIRTHDATE OR AGE*
VACCINE HISTORY (IF NOT AT THIS CLINIC)
REASON FOR VISIT*
FOR ADDITIONAL PETS: PUT NAME, SEX, BREED, COLOR AND AGE
AUTHORIZATION
*

I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. I ALSO UNDERSTAND AND AGREE TO A $3.50 MONTHLY BILLING CHARGE, 1.5% MONTHY FINANCE CHARGE AND RESPONSIBILITY FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
SIGNATURE*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
METHOD OF PAYMENT

AMEXCARE CREDITCASHDISCOVERMASTERCARDVISASCRATCHPAY
Should be Empty: