Client Registration Form

Client Registration Form
Primary Contact*

First NameLast Name
Secondary Contact

First NameLast Name
Unless otherwise noted your listed secondary contact will be authorized to make decisions regarding your pet(s).
Primary Contact's Birthday*

MonthDayYear
Date
We ask all clients for their date of birth. Your DOB is required for paying with a check and for any DEA prescription drugs that may be prescribed to your pet. We will NOT share your DOB with anyone else as it is for internal record keeping only.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number:
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Authorization

Please list the name and number of any other contacts that are allowed to make decisions on you or your pets behalf:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Please choose what your co-owner is allowed to approve on your behalf:

Preventative Care (vaccines, dewormer, medications, etc.)Comprehensive Care (bloodwork, x-rays, etc.)Emergency CareAll of the above
Please list all your pets names below:*
Pet Portal

We have a pet parent portal available to new and current clients. On this portal you will be able to access records, upload photos, request prescriptions and appointments. Please reach out if you have any questions regarding your account.

You can look up your account or create an account here: Marshall Animal Clinic Pet Portal .
Online Store

We have a online store available to our clients that is competative and has great deals and customer service. We understand that not everyone is comfortable navigating an online store, no worries! We can do your ordering for you just give us a call!

You can access your account here: Marshall Animal Clinic Online Store.
Finance Options

We accept all major credit cards, cash, check, Scratch Pay, Care Credit, Sunbit, and AllPay. We do not accept in-house payment plans but do offer third-party payment options. If you are interested in these please see our website:

Marshall Animal Clinic Payment Options
I hereby authorize Marshall Animal Clinic to examine, treat and prescribe for my pet(s). I assume full responsibility for ALL financial charges incurred in the care of my pets. I also understand that payment is always DUE AT TIME OF SERVICE. I have read and understand this policy and I accept full responsibility for all fees. All charges not paid in full within 30 days will incur interest at a rate of 1.5% per month and 18% per year. I understand that failure to pay in full will result in legal action against me. I agree to pay all costs incurred in the collection process including, but not limited to: late charges, attorney fees, and a collection agency of $100.00 or 50% of the balance assigned, whichever is greater, with or without suit. A missed appointment is a loss to everyone. Please inform us in advance if you are unable to keep your scheduled appointment. Two missed appointments (without notification) will result in a $40.00 charge. *

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Date*

MonthDayYear
Date
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Client Registration Form

Emergency Contact Authorization