Maywood's New Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Client Name

First Name Last Name

Spouse's Name

First Name Last Name

Client Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Landline

Area Code Phone Number

Cellphone

Area Code Phone Number

Email

example@example.com

Do we have permission to use your pet's images on our practice's social media pages?

Yes No

Payment Policy:

I understand that The Maywood Veterinary Clinic does not accept payments on account. We require payment for services in full when services are rendered. In the case of non-payment, I realize that I am responsible for a collection agency fee of $16.00 and/or attorney fees necessary to collect the full amount due to The Maywood Veterinary Clinic. I further agree that in case of non-payment a finance charge of 1.5% per month (18% APR) will be charged.

Please sign your signature to acknowledge our Payment Policy: *

Clear

How did you become aware of our clinic?

Drove by Internet Personal recommendation

If a friend or family member recommended us to you, whom may we thank?

First Name Last Name

PET # 1

PET # 2

PET # 3

NAME

BREED

DATE OF BIRTH (mm/dd/yyyy)

COLOR

SEX

SPAYED / NEUTERED?

At Maywood Veterinary Clinic, we wanted to make it easier and more convenient for our clients to communicate with us. So we developed an App for our clients to use!

Now, clients can do things like request appointments, request refills on medications and products, request information updates, view pet reminders, upcoming appointments, recent prescriptions, etc. Clients can call us, get directions or email us with the push of a button from the App. You can also update how you'd like us to communicate with you by setting your preferences up (email, text, postcard).

Visit www.maywoodvet.com to download our App today!