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.
Your name: *
Date: *

Month Day Year
Date
Address: *
City: *
Zip code: *
Home phone: *
*Cell phone:
Email address: *
example@example.com
Work phone:
OK to text? *

Yes No
*Additional Authorized Person(s):
*Authorized Person(s) Phone Number:
(The person stated above can make decisions on your behalf. As the primary account holder, you will still be responsible for payment
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? *
Pet Information
Pet #1 Name: *
Date of Birth (Estimate if unknown) *
Species *
Breed *
Sex *
Color *
Is your pet Microchipped?
Additional Pets
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. 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.
Signature

Clear
Should be Empty:

Additional Pets