5280 New Client Form

Name/Owner*

First NameLast Name

Co-Owner

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Co-Owner Number

Please enter a valid phone number.

Employer

Email (We use this to remind you of vaccinations due and send you email-only 5280VC promotions.)*

example@example.com

How Did You Hear About Us?

Which Client?

Which Employee?

Which Doctor/Hospital?

Pet Name #1

Breed

Species

DogCat

Birthdate/Age

Coloring

Gender

MaleFemale

Spayed/Neutered

YesNo

Microchipped?

YesNo

Tag Number#

Do you have another pet with you today?

YesNo

Pet Name #2

Breed

Species

DogCat

Birthdate/Age

Coloring

Gender

MaleFemale

Spayed/Neutered

YesNo

Microchipped?

YesNo

Tag Number#

Which pet insurance company is your pet insured under? - So we may submit your claims for you.

Previous Veterinarian (Name & Phone Number) - So we may obtain medical history.

Can we share pictures of your pet on our social media platforms?

YesNo

PAYMENT IS DUE IN FULL AT TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Returned check fee is $40. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. For hospitalized cases, a deposit may be required in advance. By submitting this form I agree to the payment terms above. WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA, DISCOVER, & AMERICAN EXPRESS. WE CAN ARRANGE FOR CareCredit, ASK OUR RECEPTIONIST FOR DETAILS

Signature

Date

New Client Form

Client Information

Current Pet Information

Payment Policy