Online New Client Form

New Client Form

Welcome to Gregg Animal Hospital!
WE KNOW YOUR PET’S HEALTH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name*

First NameLast Name
Spouse/Significant Other (name + contact number)
Telephone Number and Type (cell, landline):*
Preferred Method of Contact: text, phone, email?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Your Employer
Work Phone
Additional Phone
How did you learn about our hospital?
PET HEALTH HISTORY
Name of Pet*
Type of Pet*

DOGCAT
Sex*

MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE SPAYED
Breed*
Color*
Birthdate or Age*
Vaccine History (if not at this hospital) We can call and get records for you.
Reason for Visit*
Do you have a pet insurance provider? If yes, which one do you use?
For additional pets: list name, sex, breed, color, and age
I understand that there is a fee of $28.95 if I do not show up for or cancel my appoinment in less that 24 business hours.*

Yes
AUTHORIZATION
I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. WE ACCEPT VISA, MASTERCARD, AMEX, CARE CREDIT, CASH, AND CHECK. A $35 SERVICE CHARGE WILL BE ADDED TO ALL RETURNED CHECKS.I UNDERSTAND THAT TO PREVENT THE SPREAD OF INFECTIOUS DISEASES, ALL HOSPITALIZED AND BOARDED PETS MUST BE CURRENT ON ALL VACCINATIONS AND FREE OF BOTH EXTERNAL AND PARASITES
SIGNATURE*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
METHOD OF PAYMENT

AMEXCARE CREDITCASHDISCOVERMASTERCARDVISACHECK
8309 Two Notch Road

Columbia, SC 29223

Tel/Text: 803.736.0006

email: gregganimal@nva.com

website: gregganimal.com
Should be Empty:

New Client Form

PET HEALTH HISTORY

AUTHORIZATION