Online New Client Form

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name

First NameLast Name
MI
SPOUSE
SS# OR DL#
Check payments will not be accepted without this information.
CELL PHONE #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS
example@example.com
YOUR EMPLOYER
SPOUSE EMPLOYER
WORK PHONE
SPOUSE WORK PHONE
ADDITIONAL PHONE
SPOUSE CELL PHONE
HOW DID YOU LEARN ABOUT OUR CLINIC?
PET HEALTH HISTORY
NAME OF PET
TYPE OF PET

Other
SEX
BREED
COLOR
BIRTHDATE OR AGE
VACCINE HISTORY (IF NOT AT THIS CLINIC)
Date of Scheduled Appointment (if you have not scheduled yet, put none.)
REASON FOR VISIT
FOR ADDITIONAL PETS: PUT NAME, SEX, BREED, COLOR AND AGE
AUTHORIZATION
Type a question

I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION. I ALSO UNDERSTAND AND AGREE TO RESPONSIBILITY FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
SIGNATURE
DATE OF SIGNATURE

MonthDayYear
Date
METHOD OF PAYMENT
Should be Empty:

PET HEALTH HISTORY