Thank you for allowing us the opportuinty to care for your pet. So that we may become better acquainted, please complete the following:

Thank you for allowing us the opportunity to care for your pet. So that we may become better acquainted, please complete the following:
Client (Owner) Information*

First NameLast Name
Secondary Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Pet's Name*
Species*
Please specify "Other" Species
Breed*
Age or Birthdate*
Sex*
Color(s)*
Do you have another pet to add?*

YESNO
Pet's Name*
Species*
Please specify "Other" Species
Breed*
Age or Birthdate*
Sex*
Color(s)*
Do we have permission to use your pet's images on our hospital's social media pages?*

YESNO
Do we have permission to send records, in the future, to other veterinary facilities upon request?*

YESNO
Please email any previous records to info@maywoodvet.com
Accepted Payment Methods:

Cash, Credit/Debit Card, Care Credit

Checks are NOT accepted
Payment Policy
I understand that payment is required in full when services are rendered. Maywood Veterinary Clinic does not accept payment on account. In the case of non-payment, I will be responsible for a collection agency fee of $16.00 and/or attorney fees necessary to collect the full amount due to The Maywood Veterinary Clinic. I further understand that, in the case of non-payment, a finance charge of 1.5% per month (18% APR) will be charged.
Signature*

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