New Client Form | Mandarin AH

New Client Form | Mandarin AH

Thank you for choosing Mandarin Animal Hospital. Please complete this form to help us deliver the best and most comprehensive veterinary care for your pet now and in the future.
Title:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Email*
**E-Mail is for internal use only and will not be shared.
Secondary Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer
Work Phone
Please enter a valid phone number.
Are you over the age of 62?
Are you a member of the US military?
Emergency Contact Name / Number
Whom may we thank for referring you?
Pet #1 Information
Pet's Name
Pet Type
Breed
Gender
Color
Pet's Birthday/Age
Microchip Number
Last Vaccination Date
Vaccine Types
Diet
Treats
Table Food
Past Health Problems
Current Medications
Allergies / Reactions
Date of Dog's Last Heartworm Test
On Heartworm Prevention?

YesNo
Pet #2 Information
Pet's Name
Pet Type
Breed
Gender
Color
Pet's Birthday/Age
Microchip Number
Last Vaccination Date
Vaccine Types
Diet
Treats
Table Food
Past Health Problems
Current Medications
Allergies / Reactions
Date of Dog's last heartworm test
On Heartworm Prevention?

YesNo
I hereby authorize the veterinarians at Mandarin Animal Hospital to examine, prescribe to, and/or treat my pet(s) as I approve. I understand that payment is due at the time that services are rendered, and I have the right to ask for an estimate of cost at any time. Mandarin Animal Hospital accepts the following forms of payment: Visa, MasterCard, Discover, American Express, Cash, Check, and Care Credit.

I approve and agree ALL new clients are subject to a $50.00 and/or portion of a non-refundable deposit per pet upon scheduling a first-time exam. This fee will be applied to the invoice upon check out after the appointment is completed. All surgical procedures are required to place a $150.00 non-refundable deposit to hold a surgical procedure spot. This will also be applied to the invoice upon payment of procedure or pick up of the patient.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

New Client Form | Mandarin AH

Pet #1 Information

Pet #2 Information