New Client Form

(219)942-0909 www.merrillvillevets.com
Owner*
Address*
City*
State*
Zip*
Home Phone*
Work
Cell
Spouse
Spouse Cell
Emergency Contact
Phone
Email Address*
example@example.com
How did you learn about our Practice?

WebsiteGoogleFacebookDrive by2x2 RescueReferral
Referred by: *
Reason for choosing a holistic veterinarian?*
Name of Pet*
Dog or Cat *
Breed*
Color
Birth Date

MonthDayYear
Date
Sex
Neutered/Spayed
Date of Last Vaccinations

MonthDayYear
Date
Health Issues/ Pre-existing Conditions*
Authorization and Financial Responsibility

I authorize the veterinarians at Southlake Animal Hospital to examine, prescribe for, and treat the above described pet. I understand that the charges for these services must be paid for at the time of service and that a deposit may be required for hospitalized patients. Payments can be made by cash or credit card.Personal checks may be accepted in connection with established accounts under unusual circumstances, but only with acceptable current, state-issued picture identification.I agree to pay for all services and products at the time such services or products are provided. I further agree to pay all costs of collection, including, but not limited to, all costs, expenses, fees of dishonored checks, attorney fees and all other charges or fees incurred in connection with recovering any amounts due or owing to Southlake Animal Hospital.

**NEW CLIENT DEPOSIT AGREEMENT

I, as a cardholder, hereby authorize Southlake Animal Hospital of Merrillville IN to charge my credit card for my new client deposit (one time fee of $50) and confirm that the information for the credit card and billing address is complete and accurate.

I have been informed that this is a non-refundable deposit, that once made can not be credited back to my bank account.
Signature of Owner (Sign with mouse, if on phone or tablet with finger)

Clear
Date

MonthDayYear
Date
Should be Empty: