New Client Form

New Client Form

Companion Animal Clinic
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Date of Birth *

Month Day Year
Date
Email Address *
example@example.com
Secondary Person on Account (if applicable)

First Name Last Name
Pet's Name *
Pet's Breed *
Pet's Color *
Is your pet... *

Male Female
Have they been spayed/neutered? *

Yes No Unknown
What is your pet's date of birth, or, if unknown, approximate age? *
Would you like to add a photo of your pet to their medical file? If so, please click Browse Files to add one. If not, we will take one during your appointment.

Browse Files

Cancel of
Occasionally, we post photos of pets onto social media highlighting their good care, excellent at-home treatment, behavior, or funny antics. Only positive things will be posted, never anything negative!

I grant to Companion Animal Clinic, its representatives and employees, the right to take photographs of me and/or any of my pets, and to copyright, use and publish the same in print and/or electronically.

I agree that Companion Animal Clinic may use such photographs of me and/or my pets with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, social media, and other Web content.
*

The above may publish photos of me and/or my pets. The above may NOT publish photos of me and/or my pets.
By signing this document, I hereby authorize the staff of Companion Animal Clinic to examine, prescribe for, treat, or perform surgery on my pets. I also consent to the administration of such anesthetics or sedatives as are necessary in the performance of such.

I agree to pay fees for services rendered at the time the patient is discharged or when service is otherwise terminated.

Any returned checks or unpaid balances are subject to a $25.00 returned check fee, monthly finance charges and/or will be sent to a collection agency.

If I miss an appointment without calling Companion Animal Clinic to inform them beforehand, I understand that I will be charged a $25.00 deposit if I want to schedule another appointment. If I miss the second appointment without notifying Companion Animal Clinic beforehand, the deposit becomes nonrefundable.

I understand that the staff is not on premises 24 hours a day.
Signature *

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Date

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Date
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