New Client Form

New Client Form

Please fill out this form prior to your pet's appointment!
Primary Owner's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid cell phone number.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Work Phone Number
In case of emergency during your working hours!
May we share your pet's photo on our website/social media?*

Yes, please!No thank you
How did you hear about us? We'd like to thank them!
Please indicate which person(s), business, or Veterinarian recommended our practice.
Select to add a Secondary Contact

Secondary Contact Name*

Full NameRelation
Phone Number*
Please enter a valid cell phone number.
Does this person have permission to make medical decisions on your behalf for your pet(s)?*

YesNo

Last Step!

Thank you for providing your information! We can't wait to see you!
I hereby authorize Southern Hills Veterinary Hospital to render surgical and/or medical care for my pet(s). I understand that payment is due in full at the time services are rendered. I/we understand and agree that any credit granted shall be paid promptly in accordance with terms and agreements, that the credit grantor may add a $35 late fee for any balances not paid one month after services rendered, and in the event of default to pay reasonable collection charges and/or attorney fees.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Pet Information