New Client Form

Date

MonthDayYear
Date
Owner Name*
Spouse/Joint Owner
Street Address*
City*
State*
Zip*
Home
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Work
Please enter a valid phone number.
Email
example@example.com
Driver's License #
SS#
Employer
What is the best way to reach you?*
In the event we are unable to reach you, who may we contact?*
Name
Emergency contact phone number*
Please enter a valid phone number.
Does this person have your consent to pick up/drop off your pet(s) in emergency situations?*
How did you hear about us?
Who referred you? We would love to thank them!
How many pets do you have? Dog(s)
Dog(s)
Cat(s)
Other (specify)
Who is your previous/current Veterinarian?
Phone
Do you have medical records for your pet(s)?*
If you do not have your pets medical records, may we contact your previous veterinarian?
ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES
New clients are required to pay Office Visit Fee up front on first visit

We accept all major credit cards, debit cards, cash, Apple & Google Pay, Care Credit, and Scratch Pay

I understand every effort will be made to achieve a successful outcome and to provide all possible safety in hospital care and handling. I hereby authorize Shoals Animal Hospital to receive, prescribe for, treat or perform surgery upon the pets that are listed on my account. I understand there is no in-house billing. I agree to pay all fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable cost of collection, attorney fees and court cost in the event that collection becomes necessary. There is a $34 returned check fee. I understand that veterinary service is provided after hours for hospitalized or boarding pets as necessary in the judgement of the veterinarian in charge and additional fees may apply for these services. Continuous presence of qualified personnel may not be provided.
Signature of Owner*

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Date

MonthDayYear
Date
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ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES