Holladay Vet Hospital | New Client Information

New Client Information
Client Name *

First Name Last Name
Client Email *
example@example.com
Verify Email Address *
What date and time is your appointment? *

Month Day Year
Date Hour Minutes AM/PM Option
Client Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred Phone Number *

Area Code Phone Number
Type of Phone
Would you like to receive health & appointment reminders via text? *

Yes No
Secondary Phone Number

Area Code Phone Number
Preferred Method of Contact
Co-Owner Name

First Name Last Name
Co-Owner Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Co-Owner Phone Number

Area Code Phone Number
How did you hear about us? If referred by a current client, what is their name? *
I give permission to Holladay Veterinary Hospital to share pictures and stories of me and my pet(s) on their website and on their social media. *

Yes No
FINANCIAL POLICY - PLEASE READ & SIGN
1. Full payment is due at the time of service/discharge.
  We accept cash, Visa, MasterCard, Discover, American Express, Care Credit and debit cards.
2. For pets brought in by unaccompanied minors, non-emergency treatment will be denied unless payment arrangements have been pre-authorized and arranged with our staff.
3. Patient pick-ups by non-owners must be pre-authorized and payment arrangements made in advance.
4. Please give us 24 hours notice of cancellation of your appointment so we may offer the time to another patient in need. If you do not show for a scheduled appointment, a $57 fee will be charged to your account. This will need to be paid when you schedule your next appointment.
I have read, understand and agree to the above Financial Policy: *

First Name Last Name
Date *

Month Day Year
Date
Signature

Clear

New Client Information

PATIENT INFORMATION