New Client Form

Welcome To East Poplarville Veterinary Clinic, PA!

"Your Pet, Your Friend. You Care, We Care"

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information we will need as we support your pet's needs today and in the future.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Spouse's Name
Phone Number
Please enter a valid phone number.
Mobile
Spouse's Phone
Please enter a valid phone number.
Mobile
Email
example@example.com
Date of Birth

MonthDayYear
Date
Driver's License
Place of Employment
Phone Number
Please enter a valid phone number.
Emergency Contact
Phone
How did you hear about us?
Who can we thank?
We will gladly prepare a treatment plan if you desire. This will be important to you since ALL PROFESSIONAL FEES ARE DUE ATTHE TIME SERVICES ARE RENDERED and a deposit may be required for treatment. In cases of extensive medicalor surgical procedures, when full payment may be difficult at discharge, we take Master Card, Visa, Discover, Care Credit or can establish a payment arrangement if approved in advance of the treatment. There will be a $35.00 service charge for any check returned unpaid. Initials :
Initials
PLEASE INDICATE YOUR PREFERRED CHOICE OF PAYMENT:*

CashCheckCredit CardCare Credit / ScratchPay
To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventive care, and the appropriate charges will be assessed in the discharge invoice. You also authorize the veterinarian to examine, prescribe for, and/or treat your pet(s) and assume responsibility for all charges incurred.
Initials
Pet Information
Pet Name
Species
Breed
Sex
Date of Birth or Age
Color
Microchip?
Insurance?
Up to date on vaccines?
Please list prior illness, allergies, special diets, or medications
Do you have another pet to add?

YesNo
Pet Name
Species
Breed
Sex
Date of Birth or Age
Color
Microchip?
Insurance?
Up to date on vaccines?
Please list prior illness, allergies, special diets, or medications
Do you have another pet to add?

YesNo
Pet Name
Species
Breed
Sex
Date of Birth or Age
Color
Microchip?
Insurance?
Up to date on vaccines?
Please list prior illness, allergies, special diets, or medications
If your pet(s) travel ( or have traveled):
When?
Where?
Initial if we have your permission to share pictures of your pet on our social media:
Signature of Responsible Agent for Pet(s)

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Date

MonthDayYear
Date
If you have any vaccination history, medical records, or information to share please attach below

Cancelof
Should be Empty:

Pet Information

If your pet(s) travel ( or have traveled):