Online New Client Form

WE KNOW YOUR PET’S HEATH 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!

Are you a new client?

Owner Name*

First NameLast Name

Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code

EMAIL ADDRESS*

example@example.com

CELL PHONE #*

Alternate PHONE #*

Are you active or retired military?*

Are you active or retired military?

ActiveRetiredNeither

NAME OF PET*

TYPE OF PET*

DOGCAT

Sex*

BREED*

BIRTHDATE OR AGE*

COLOR*

Is your pet current on rabies?*

REASON FOR VISIT*

Please list any chronic medical conditions or medications your pet is taking*

FOR ADDITIONAL PETS: PUT NAME, SEX, BREED, COLOR AND AGE

HOW DID YOU LEARN ABOUT OUR CLINC?*

CURRENT VETERINARIAN AND PHONE NUMBER*

Do you authorize Night Watch Elite Animal Emergency to use your pet's name, image and case details for social media use?

I understand every effort will be made to achieve a successful outcome and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of services and completed, unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs, and collection agency fees. I hereby authorize Night Watch Elite Animal Emergency to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reactions occur.

SIGNATURE OF OWNER OR AUTHORIZED CARE TAKER*

DATE OF SIGNATURE*

Date

PRINTED NAME OF OWNER OR AUTHORIZED CARE TAKER*

First NameLast Name

Car Make * Car Model/Color .