East Holland Veterinary Clinic- New Client Form
Customer Information:
Owner Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Drivers License #
*
Social Security #
Secondary Person on account
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Primary Phone Number
*
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Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
E-mail
*
Can we text you for reminders?
*
Yes
No
Are you active military or a veteran?
*
Yes
No
Pet Information:
1st Pet
Pets Name
*
Pets Species
*
Pets Breed
*
Pets Date of Birth
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Month
-
Day
Year
Date
Pets Sex
*
Male
Female
Neutered Male
Spayed Female
Does your pet have previous medical records from another veterinarian, please list the clinic below so we can call to get records ahead of your visit?
*
Yes
No
Other
Is your pet microchipped?
*
Yes
No
Other
Record Release- Please choose 1 of the following options
*
I authorize East Holland Veterinary Clinic to release my pet's records in any circumstance without contacting me
I do not authorize East Holland Veterinary Clinic to release my pet's records unless you have my verbal permission
Other
How did you hear about us?
What platform?
*
Please Select
Yellow Pages
Google search
Word of mouth
Facebook
Other (Please specify...)
Please leave the name of person/persons that referred you so we can Thank them.
Social Media Release
Within The Context Of Our Business And Pet Health, We Would Like To Use Pictures, Videos And/Or Information about Your Pet. Do You Wish For Your Pet To Participate On Our Social Media Site? (Required)
*
Yes
No
Late Cancellation/No Show Policy
In order to be respectful of the medical needs of our Community, please be courteous and call promptly if you are unable to attend an appointment. If it is necessary to cancel your scheduled appointment, we require that you call 24 business hours in advance. A fee of $25 will apply if a scheduled appointment is missed or not canceled within 24 business hours. Appointments are in high demand, and your early cancellation will give another patient the possibility to have access to timely medical care.
*
I agree to East Holland Veterinary Clinics No-Show policy as described above. I understand that I will be charged a $25 fee if I fail to cancel my appointment at least 24 business hours in advance.
Payment Policy
We accept Cash, Credit Card, Square Pay, Apple Pay, Samsung Pay, Care Credit & Scratch Pay. Payment is expected when services are rendered. We will gladly prepare you a written quote for services prior to any treatment of your pet, if you desire. If a balance is incurred on your account a finance fee of 1.5% (minimum monthly finance charge of $5) will be applied to account.
Signature
*
Todays Date
*
-
Month
-
Day
Year
Date
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