Language
English (US)
Spanish (Latin America)
New Client Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Pet Name
Type of Pet
Dog
Cat
Other
Sex
Male (intact)
Male (neutered)
Female (intact)
Female (neutered)
Breed
Color
Birth Date or Age
Additional Pets: Include Name, Sex, Breed, Color, and Age
Other people authorized to make decisions and receive information about my pet:
Name and phone number of individuals authorized. Without authorization, we will NOT be able to give out information.
AUTHORIZATION
I hereby authorize Lone Tree Animal Care Center to examine, prescribe for, and/or treat my pet(s). I assume full responsibility for all charges incurred for the care of all my pets on my file. I also understand that payment is due at the time services are rendered and that a deposit may be required for surgical treatment or hospitalization. I also assume responsibility for any collection charges for a balance due for any reason.
Signature
Signature Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: