New Client Information

New Client Information

Welcome to Bradford Veterinary Clinic! Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you may have concerning your pet’s health. To ensure the best care possible, please take the time to fill in this form completely.
Client Name*

First NameLast Name
Pet's Name*
Physical Address*

Street Address

Mailing Address, if different

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Reason For Requesting Visit (Establish Care, Urgent Medical Need, etc.)*
Previous Veterinary Clinic *
Previous Veterinary Clinic Phone Number*
Please enter a valid phone number.
Do you authorize Bradford Veterinary Clinic to contact and receive records from previous veterinary clinic?*

YesNo
I hereby authorize the veterinarian(s) of Bradford Veterinary Clinic to examine, prescribe for, or treat my animals. I assume responsibility for all charges incurred in the care of this animal. I also understand that all charges incurred are due in full at the time of release and that a deposit may be required for surgical treatment. I also understand that if for any reason my account is overdue or sent to collections, I am also responsible for any bank, interest, collection and/or attorney’s fees.
Signature*

Clear
Should be Empty: