New Client Form

Client Details:

All asterisked fields are required before form can be submitted.
Primary Owner Full Name *

First Name Last Name
Secondary Adult Full Name

First Name Last Name
Secondary Adult Relationship to Primary Owner?

Spouse Partner Other
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Alternate/Work Phone Number
Please enter a valid phone number.
E-mail *
example@example.com
What is the best method of contacting you regarding reminders about your pet’s needs? *

Mail Email
Secondary adult address (if different than Primary Owner)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary adult phone number (if different than Primary Owner)
Please enter a valid phone number.
Authorization for Emergency Care

Should a medical emergency arise, while my pet is in the care of Howard County Animal Hospital, I authorize the medical staff to administer a tranquilizer or perform such emergency procedures as may be deemed necessary to stabilize my pet. I agree to pay, in full, for all necessary services rendered for and to my pet. I understand that emergency services that are beyond the scope of this practice may require a referral and/or transfer to the closest available full-service emergency vet center.

I have read these conditions for the care of my pet. I hereby authorize Howard County Animal Hospital to determine to execute any/all necessary care to ensure the best outcome for my pet. I understand that, due to the nature of medical emergencies, the best course(s) of action may not provide a guaranteed outcome.
Primary Owner or Authorized Pet Representative Signature *

Clear
Date *

Month Day Year
Date
Please list any other authorized adults over the age of 18 years that are allowed to make medical and financial decisions on behalf of this pet:
Name and Relationship to Primary Owner
Name and Relationship to Primary Owner
May we post digital pictures of you and/or your pet(s) on our social media sites? *

Yes No Pet(s) only
Please note that we require all services to be paid in full at time of discharge.

We will gladly prepare an estimate for services. Please ask the Doctor or a Staff Member.

Payment methods accepted at Howard County Animal Hospital:

Personal Check | Discover/ Visa/ Mastercard/ American Express | Care Credit | Cash
Should be Empty:

Client Details: