New Client Information

New Client Information
Owner Name*

First NameLast Name
Owner Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Owner Email*
example@example.com
Other people authorized to make decisions for my pet:
Pet Name
Type of Pet

DogCatOther
Sex

Male (intact)Male (neutered)Female (intact)Female (neutered)
Breed
Color
Birth Date or Age
Please add information for all pets you own:*
Upload any health or vaccine records for your pets:

Cancelof
If you don't have any records, type the name of the practice your pet last visited and we will contact them for records:
Does your pet have insurance?

YesNo
If yes, who is the provider?
If no, are you interested in learning more about pet insurance during your appointment?

YesNo
Upload or take a picture of your pet for our records:
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*

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Signature Date*

MonthDayYear
Date
Should be Empty: