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
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 and sign:
- Full payment is due at the time of service/discharge
- We accept cash, Visa, MasterCard, Discover, American Express, Care Credit and debit cards
- 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
- Pick-ups by non-owners must be pre-authorized and payment arrangements made in advance
- Please give us 24 hours notice of cancellation of your appointment so we may offer the time to another patient. No-show appointments will be assessed a $59 no-show fee
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