New Client/Pet Registration

Today’s Date*

Date

Primary Contact:*

First NameLast Name

Current Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email Address *

example@example.com

Contact Number*

Please enter a valid phone number.

Employer

Business Phone

Please enter a valid phone number.

Secondary Contact:

First NameLast Name

Secondary Contact Number

Please enter a valid phone number.

How Did You Hear About Us?

Saw Our SignGoogleSocial MediaReferred

If referred, who were you referred by?

Payment is DUE at the time of service. We DO NOT offer payment plans. We Accept CASH, VISA, MASTERCARD, DEBIT CARDS, AND CHECKS.

We would appreciate a call one week in advance to schedule and a 24-hour cancellation notice.

If you cancel an appointment with less than 24-hour notice, it will be considered a no-show. All no-shows will result in a $25.00 charge placed on the account.

A $100 deposit is required at the time of scheduling to reserve your surgery appointment. This deposit will be applied toward your final bill. If you fail to attend your scheduled appointment, the deposit will be forfeited and retained by the clinic.

We require a physical exam for each pet at least once per year. If it has been more than a year since we have seen your pet, we will be unable to provide support or sell products until an exam is performed.

Please allow up to 48 hours to fill any prescription request, including Heartworm prevention. If we are unable to confirm consistent heartworm prevention, the Doctor may require a Heartworm Test or Physical Exam before filling. One of our team members will call you when the prescription is ready to be picked up.

A copy of this sheet can be made at your request.

Primary Signature:*

Date*

Date

Secondary Signature:

Date