EEAH Client Information

New Client Information
Owner Information
Full Name*

First NameLast Name
Co-Owner's Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Home Phone Number
Please enter a valid phone number.
Co-Owner Phone Number
Please enter a valid phone number.
E-mail*
example@example.com
Do you prefer text, email or phone calls for quick updates or reminders?*

TextEmailPhone Call
How did you hear about us?*
Please write in the box below how you heard about us if option not listed above or if someone referred you please write their name.
Patient Information
Pet's Name*
Species*

CanineFeline
Breed*
Color/Markings*
Gender*

MaleMale NeuteredFemaleFemale Spayed
Date of Birth/Age *

Please fill out this section if you have another pet you would like added to your account:
Pet's Name
Species

CanineFeline
Breed
Color/Markings
Gender

MaleMale NeuteredFemaleFemale Spayed
Date of Birth/Age

Do we have permission to post your pet's photo on our social media pages?
To help us provide the best care for your patient please let us know other hospitals your pets ave received medical treatment or vaccinations from:
Name and phone number of Veterinary Hospital or Shelter we can obtain records from?blanks Area Code Phone Number
Payment Policy
FULL PAYMENT IS EXPECTED UPON RENDERING OF SERVICES deposits are required on major medical/surgical cases, trauma cases and emergency work where hospitalization is required. We DO NOT carry open accounts and hope these four alternatives are convenient for you:

CashVisaMastercardAmerican ExpressDiscover
To prevent the spread of infectious diseases and parasites, hospitalized or boarded animals must be current on a physical exam provided by Evans East Animal Hospital within on year. All vaccines must be current and the pet is to be free of internal and external parasites.

I hereby authorize Evans East Animal Hospital to provide the physical examination, vaccines and parasite control when needed. I authorize Evans East Animal Hospital to treat and care for my pet and I accept and agree to pay the costs associated with this care. I also understand and agree to pay any costs and charges necessary for the collection of any amount not paid when due.
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New Client Information