NEW CLIENT FORM

PIONEER VET CLINIC & RESORT

65073 US HWY 60 East, Ponca City, OK 74604
NEW CLIENT FORM
Please print clearly and all fields are required.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Driver's License # or Valid ID*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*
Main Phone Number*
Cell Phone Number*
Work Phone Number*
Email Address*
example@example.com
Employer*
Spouse/Other
Cell
Emergency Contact Name*
Emergancy contact Cell Number*
How will you be paying for today's visit?*

CashCredit CardInsuranceCheck
Temporary checks are not accepted. All returned checks will be assessed a return check fee of $25 and submitted to the Osage County DA for prosecution. Full payment is due at the time services are rendered. Please initial if you understand and agree to this: I certify that I am at least 18 years of age and not under the influence of drugs/alcohol.
Initials*
Pet's Name*
What species is your pet?*

DogCatGoatHorse
Other
Breed*
Color*
Age*
What is the gender of your pet?*

MaleNeutered MaleFemaleSpayed Female
DOB (if known)
Allergies known
Current Medications
Date of Last Vaccinations*

MonthDayYear
Date
Clinic Name
Is your pet on heartworm prevention?*

YesNo
Is your pet on flea and tick prevention*

YesNo
Other
Legal Consent & Authorization

I, the undersigned owner, agent of the owner, or Good Samaritan, authorize Pioneer Vet Clinic to perform such diagnostic, therapeutic, and/or surgical procedures as are necessary and advisable for treatment and maintenance of my pet's health and well-being.

While I expect all procedures to be done to the best abilities of the professional staff, I realize no guarantee or warranty can ethically or professionally be made regarding results or cure.

I authorize the practice owner, manger, and staff to provide services as requested, in emergency circumstances, or in the event I cannot be reached by phone to follow through with procedures and diagnostics deemed necessary by the veterinarian for the well-being of my pet on a continuing basis until further advised.

I authorize Pioneer Vet Clinic to use pictures of my pet(s) in my medical record, on their website, on social media, and advertising.

A $2 statement fee is automatically applied to all statements when printed.
Owner/Agent/Good Samaritan's Signature*

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Date*

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Date
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PIONEER VET CLINIC & RESORT

NEW CLIENT FORM