New Customer Registration Form

Full Name*

First NameLast Name

How many adults and/or children live in the home?

How many dogs/cats do you care for?

What is you household net income?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

For medical records, please provide your email address:*

example@example.com

How did you hear about us?*

Other*

Are you needing your pet to be seen immediately? If so, please explain

*This does NOT guarantee a same day appointment, but will make all efforts if this is an emergency

IMPORTANT INFORMATION:

CHEW Animal Clinic operates differently than other clinics. We require an on-line authorization/refundable deposit PRIOR to all appointments. If you do not fill out your on-line authorization, your appointment will be canceled.

Why do we require these on-line authorizations? Having these authorizations completed prior to the appointment, our DVM has a better understanding why your pet is coming to CHEW. In addition, having these authorization done in advance, it helps us expedite the intake process so we have more time with your pet during their allotted appointment time.

Why do we require a refundable deposit? CHEWs overhead is like any other small animal clinic. However, in most cases, our services are half the price. Because of this, we cannot afford to have people miss their appointments. By requiring a refundable deposit, CHEW has decreased the number of patients who have not shown up for their appointments by over 87%. In addition, we have many pets who are waiting to be seen by one of our DVMs. If you are unable to make your appointment, and cancel at least 24 hours in advance, we are more likely to fill that appointment time with a pet in need of medical care.

CHEW requires a 24 hour cancellation or the system automatically removes your deposit from your account, and it is no longer refundable.

Your understanding is greatly appreciated,
CHEW Team

I understand I will be required to pay a $25 nonrefundable deposit for all exams
I understand I will be required to pay a $50 nonrefundable deposit for all surgeries
I understand I will be required to pay a $20 nonrefundable deposit for all rechecks

I certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief.

Clear

FAMILY APPLICATION