New Client Information Form
Do you already have an appointment scheduled?
*
Yes.
No.
If you already have an appointment scheduled, please enter the appointment date and time. If you do not have appointment scheduled, please call 940-665-4478.
Client Information
Name
*
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary/Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
(Required To Verify Identity)
*
Spouse/Additional Account Holder (Optional) (This person will have the authority to make account changes and medical decisions.)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Information
Pet's Name
*
Species (Examples: Canine, Feline, Bovine, Etc.)
*
Breed (Examples: Labrador, Siamese)
*
Color
*
Age or Date of Birth
*
Sex (Male or Female)
*
Is this pet spayed or neutered?
*
Yes
No
Unsure
Payment Agreement
*
I understand that payment is due at the time of service unless other arrangements have been made in advance. I agree to pay for all services rendered and understand that all prices are a quoted estimate and additional fees may be required for any additional treatments provided.
Please check payment method
*
Cash
Credit/Debit
Check
CareCredit
ScratchPay
Do you give Refinery Road Veterinary Clinic permission to post my pets' picture(s) on social media (Facebook, Instagram, Website, Etc.)
*
Yes
No
Acknowledgement
*
I confirm that I am 18 years of age or older and I am the owner or authorized agent for the pet listed above. I authorize the veterinarians and staff of Refinery Road Veterinary Clinic to examine, treat, administer medications and perform diagnostics, surgical procedures, and/or to hospitalize my pet if the doctor(s) deem it necessary for the health, safety or well being of my pet. I acknowledge that I have read, understand, and agree with the above information.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: