New Client Form

Name*

First NameLast Name

Co-owner

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?

Patient name*

Age/birthdate*

Approx. age is ok

Breed

Color

Gender*

Is your pet spayed/neutered?*

The name of my pet's previous clinic is: . (Please fill out if your pet has been seen at any other clinic, emergency, or specialty center.)

We love social media! We would like your consent to share your pets' image on our social media and website.*

Your full name and personal information will never be used.

By selecting yes, you authorize Prestige Animal Clinic the right to use your pets photo provided for reproduction in any medium, including but not limited to; website, video, broadcast, print and any electronic means for purposes of advertising, trade, display, exhibition or editorial use. Further, you also agree to release Prestige Animal Clinic from all claims for libel, slander invasion of privacy, infringement of copyright or right of publicity or any other claim.

Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet (s) or any additional pet(s) that I add to my account verbally. I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience we accept Visa, MasterCard, American Express, Care Credit, cash and checks with proper identification. Please stop at the reception desk to review and pay for services.

I confirm that the above information is correct and that I am the owner or authorized agent of the patient (s) listed above. I also confirm that I am over the age of 18 years old.

Signature*

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