NEW CLIENT FORM

Owner's Name

First NameOwner's Last Name

Date

Address

Street Address Line 2

City

Zipcode

Phone

Format: (000) 000-0000.

Cell

Please enter a valid phone number.Format: (000) 000-0000.

Alternative Cell

Email

Please enter 'DECLINED' if you do not wish to provide an email.

Preferred Communication Method

Alternate Contact Name

Alternate Contact Cell

Employment

Work Phone

Format: (000) 000-0000.

Emergency Contact Name

Emergency Contact Phone

Format: (000) 000-0000.

Pet Information

Rows	Pet 1	Pet 2	Pet 3	Pet 4
Name
Breed
Color
Age
Male/Female
Neutered/Spayed
Medications
Special Diet

How did you choose Blackhawk Veterinary Hospital?

If "Referral" or "Other", please enter name and/or additional information

Previous Veterinary Hospital

Do you have records?

Payment is due at the time services are performed. I will be paying by:

I GIVE BLACKHAWK VETERINARY HOSPITAL PERMISSION TO POST PICTURES OF MY PET(S) ON SOCIAL MEDIA

I hereby authorize the veterinarians and their assistants to examine, prescribe for, and treat the above described pets(s). I assume responsibility for all charges incurred in the care of this animal, and I also understand that these charges will be paid at the time of release. A deposit may be required for surgical or medical treatment. In the event that any balance is not paid as agreed, the undersigned jointly and severally agree to pay all costs included in said balance. Should it become necessary to place the account with a collection agency and/or attorney for collection, the undersigned jointly and severally agree to pay reasonable collection and/or attorney fees and costs. A monthly fee of $5.00 and finance charges of 1.5% per month will be added to your account that exceeds 30 days.

OWNER/AGENT SIGNATURE

New Client/Patient Form