New Client Registration Form

Owner Details:
Full Name*

First NameLast Name
Phone Number*
Please have this phone number be of the person listed above.
Secondary Name

First NameLast Name
Secondary Phone Number
Please have this phone number be of the secondary person listed above.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
**Michigan Law requires the submission of the owners driver's license and birthdate when dispensing controlled drugs from our hospital. We may have to ask for this in order to dispense any controlled substances. **
Pet Details:
Pets Name*
Species*

CanineFeline
Breed*
Color
Sex*

MaleFemale
Spayed or Neutered?*

YesNo
Pet's Birth Date or Age*
Primary Veterinarian*
This is your pet's regular Veterinarian. Please put the name of the doctor, if known, as well as the name of the clinic
Referring Clinic*
Please list any and all specialty clinics that your pet has been to in the last two years

Treatment Authorization and Information/Photo Release
I hereby authorize ACIC to perform medical and initial diagnostice/surgical procedures on this animal as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors and assistants.

If you were referred to our clinic by another hospital or veternarian, they will require a summary of your pet's care and treatment in order for your pet's care to continue without interruptions. ACIC considers that your identication of a referring veterinarian implies your authorization to release records and information to that referring veterinarian.

Information and/or photos may be used in teaching, forms, continuing education, web site, veterinary literature and the like. I authorize the release of case/patient information for such purposes; patient condentially (names withheld) will be maintained.

Financial Policy
Payment is due as services are rendered. You may pay by cash, personal check, and accepted credit cards. In order to avoid misunderstandings, please let us know immediately if these terms are not satisfactory. There is a $25.00 returned check fee.

Authorization
I am the owner of the above pet, or am acting as the agent for the owner, and accept full financial
responsibility.
Signature Date
We are open for in person appointments. However, if you are feeling ill we would ask that you let us know so that we may offer curbside appointments, or if we need to reschedule we can.

Please make sure to have your pet fasted just in case we are able to provide any diagnostics that might be necessary. We ask that your pet refrain from food for 8 hours prior to the appointment time, but water is fine.
Should be Empty:

Owner Details:

Pet Details: