New Client Sheet

Welcome to Cicero Animal Clinic P.C.!

8803 Brewerton Road

Brewerton, NY 13029

(315) 699-0050

info@ciceroanimalclinic.com

www.ciceroanimalclinic.com

Please fill out the form so that we can add you and your pet(s) to our system. *

Name

First NameLast Name

Date:*

Date

Address:*

City:*

Zip code:*

Home phone:*

*Cell phone:

Email address:*

example@example.com

Work phone:

OK to text?*

YesNo

*Spouse/Significant Other Name:

*Spouse/Significant Other's Phone Number:

Spouse/Significant Other: Please be advised that to remove a spouse/significant other from your account, we require written mutual agreement regarding ownership of pet.

*Additional Authorized Person Name:

*Authorized Person's Relationship to Primary Account Holder:

*Additional Authorized Person's Phone Number:

Additional Authorized Person: The person stated above can make decisions on your behalf. As the primary account holder, you will still be responsible for payment. This can be a parent, pet sitter, etc, and can be removed from your account at anytime.

Occasionally we share pet's photos (without last name) on social media, if approved. Is it OK to share your pet's picture?*

How did you hear about us?*

Please let us know if someone referred you to our clinic so we can thank them. We appreciate your help in recognizing those who support our practice!

First NameLast Name

Pet #1 Name:*

Date of Birth (Estimate if unknown)*

Species*

Breed*

Sex*

Color*

Is your pet Microchipped?

Pet #2 Name

Pet #2 Date of Birth (Estimate if Unknown)

Pet #2 Species

Pet #2 Breed

Pet #2 Sex

Color

Is Pet #2 Microchipped?

Payment is required at the time of service. If you are planning to pay with a check, you must show a valid driver’s license or non driver ID card. We do NOT accept starter checks or checks from new clients. If paying by credit card, the card must have a valid signature or show proof of ID. If paying by Care Credit, you must show two forms of ID and can only be used by the card holder or authorized agent.

Please be advised that we use Talkatoo (a veterinary dictation program) in our exam rooms. The recordings are used for medical record transcription and are private.

I acknowledge and agree to Cicero Animal Clinic, P.C.'s payment policy and exam room recording protocol.

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Signature*

Pet Information

Additional Pets