New Client Form 2023

Client and Patient Information

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Primary Account Holders Full Name

First NameLast Name
Spouse/Co-Owner Name
Primary Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #*

Area CodePhone Number
Spouse/Co-Owner Phone #

Area CodePhone Number
Is your primary phone number a mobile number?*

YesNo
Driver's License #:*
Primary Account Holders License #
DL Expiration Date*

MonthDayYear
Date
Employer
Work Phone #

Area CodePhone Number
Co-Owner's Employer & Phone #
Emergency Contact *

First NameLast Name
Emergency Contact Phone #*

Area CodePhone Number
How did you hear about us?

WebsiteKMUWGoogleFacebook
May we have permission to use your pet's photo on our social media accounts?*

YesNo

Type a question

Previous Medical Records: Clinic Name and Phone #
We offer Military and Senior Citizen discounts. Do you qualify? Military ID or Drives License will be required for verification before applying the discount.*

Military (Active/Veteran)Senior CitizenNeither
I agree to pay any costs and charges necessary for the collection of any amount not paid when due.

A full payment is required at the time services are rendered. We do NOT carry open accounts.

We offer a variety of Wellness Plans that allow you to make monthly payments. Ask US for details.

We accept the following: Cash, Check, Visa, MasterCard, Discover, American Express, Care Credit, Scratch Pay.

Signature of owner or authorized representative:
Signed*

Clear
Date*

MonthDayYear
Date
THANK YOU for bringing your pet to our hospital!
404 S. Edgemoor, Bldg 100

Wichita, KS 67218

316-683-4641

www.skaervet.com
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Client and Patient Information