East Holland Veterinary Clinic- New Client Form

East Holland Veterinary Clinic- New Client Form
Customer Information:
Owner Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Drivers License # *
Spouse Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

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:
Date 1st appt scheduled *

Month Day Year
Date Hour Minutes AM/PM Option
Pets Name *
Pets Breed *
Pets Date of Birth

Month Day Year
Date
Pets Sex *
Does your pet have previous medical records from another veterinarian? *

Yes No
Is your pet microchipped? *

Yes No
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 I authorize release of my pet's medical records in case of emergency situation only
How did you hear about us?
What platform? *
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
No Show/Late Cancellation 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 may apply if a scheduled appointment is missed or not cancelled 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.
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.
Signature *

Clear
Todays Date *

Month Day Year
Date
Should be Empty:

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East Holland Veterinary Clinic- New Client Form

Customer Information:

Pet Information:

How did you hear about us?

Social Media Release

No Show/Late Cancellation Policy

Payment Policy