New Client Form

New Client Form

All services must be paid at the time of treatment. Thank you! We accept Cash and all major Credit Cards including Care Credit. No Checks Accepted
Client Information
Client's Name

First NameLast Name
Spouse Name

First NameLast Name
Primary Phone

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB (required by state)
Driver Lie or SS#
Email
example@example.com
Emergency Contact

First NameLast Name
Emergency Phone Number

Area CodePhone Number
Authorized User: A person authorized by the primary account owner to bring your pet to appointments and make medical decisions on your behalf.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
Pets Information
Name
Species
Breed
Age
Sex
Microchip
Indoor/Outdoor/Both
When is your scheduled appointment?
New Client & Patient Policy Acknowledgment
Thank you for choosing our hospital for your pet’s care. Please review the following policies carefully:
- The primary owner listed on the account is required to be present at the first appointment.
- All pets must arrive on a leash or secured in a pet carrier at all times. If your pet is in a carrier, please do not open the carrier unless instructed by a staff member.
- Authorized users may bring pets to appointments; however, authorized users must be 18 years of age or older.
- For payments made using a credit card or CareCredit account, the cardholder must be present with a valid photo ID at the time of payment.
  Please provide any previous veterinary medical records prior to or at the time of your appointment.
- All patients 3 months of age and older are required to have a current Rabies vaccine to be seen by our hospital unless medically exempt with veterinarian documentation.
Should be Empty:

New Client Form

Client Information

Pets Information