New Client Form

New Client Form

To update our records please complete the following form:
Owner Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number- Cell
Please enter a valid phone number.
Phone Number- Home
Please enter a valid phone number.
Client Date of Birth

Month Day Year
*Required
Email
example@example.com
Name of Employer: blanks
Work Phone Number
Please enter a valid phone number.
Spouse or Co-Owner Name

First Name Last Name
Address- If different than Primary Owner

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Co-Owner/Spouse Phone
Please enter a valid phone number.
Co-Owner/Spouse Date of Birth

Month Day Year
*Required
Email
example@example.com
Co-Owner/Spouse Employer blanks
Co-Owner/Spouse Work Phone Number
Please enter a valid phone number.
Name of anyone else authorized to order treatment or obtain patient information: blanks
Estimates and Payment

We will gladly prepare a written estimate of service fees, if you desire (please ask your doctor).

All professional fees are due at the time that services are rendered.

We accept Cash, Visa, Mastercard, Discover, American Express, Care Credit and Scratch Pay. We NO longer accept personal checks. Returned checks are subject to a $35 returned check fee.

In the case of extensive medical or surgical procedures, we do require a deposit. We offer Care Credit and Scratch Pay financing for qualified clients. Please ask a receptionist for details.

All balances are subject to a monthly finance charge. If it becomes necessary to send your account to a collection agency, you are responsible for all collection fees incurred.

To prevent the spread of infectious diseases, all hospitalized patients must be current on vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and also consents to adding any necessary service charges to client invoice to achieve this level of preventative care.

I HAVE READ THE PREVIOUS STATEMENT AND AGREE TO THE TERMS STATED:
Signature

Clear
Brighton Eggert Animal Clinic and Pet Resort has permission to use my pet's likeness in any digital media format (e.g., photo, video, website and other web-related publications) without payment.

Yes No
Signature

Clear
To learn more about our Pet Annual Wellness Plans (PAW Plans), visit our website. Click the "Begin Enrollment" button, to start your enrollment prior to your pet's appointment. https://www.brightoneggert.com/services/paw-plans.
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